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Plan to Consolidate Community Care Programs

U.S. Department of Veterans Affairs

Surface Transportation and Veterans Health Care


Choice Improvement Act of 2015
Title IVVeterans Provisions
VA Budget and Choice Improvement Act

Plan to Consolidate Programs of Department of


Veterans Affairs to Improve Access to Care

October 30, 2015

Plan to Consolidate Community Care Programs

Table of Contents
1.0

Executive Summary ........................................................................................... 7

2.0

Purpose of the Report ...................................................................................... 13

3.0

Introduction....................................................................................................... 15

4.0

3.1

Stakeholder Feedback ............................................................................ 16

3.2

Future of VA Health Care ........................................................................ 18

3.3

Care Coordination ................................................................................... 21

3.4

Alignment with MyVA .............................................................................. 25

3.5

Impact to Veterans, Community Providers, and VA ................................ 26

3.6

Implementation Dependencies and Requirements.................................. 27

Plan to Consolidate Community Care Programs .............................................. 28


4.1

Element 1: Single Program for Non-Department Care Delivery .............. 28

4.2

Element 2: Patient Eligibility Requirements ............................................. 36

4.3

Element 3: Authorizations ....................................................................... 45

4.4

Element 4: Billing and Reimbursement ................................................... 48

4.5

Element 5: Provider Reimbursement Rate .............................................. 51

4.6

Element 6: Plan to Develop Provider Eligibility Requirements ................ 54

4.7

Element 7: Prompt Payment Compliance ............................................... 61

4.8

Element 8: Plans to Use Current Non-Department Provider Networks and


Infrastructure........................................................................................... 63

4.9

Element 9: Medical Records Management ............................................. 66

4.10 Element 10: Transition Plan .................................................................... 72


5.0

Estimated Costs and Budgetary Requirements ................................................ 87

6.0

Legislative Proposal Recommendations .......................................................... 93


6.1

Immediate Improvements to the Veterans Choice Program .................... 94

6.2

Establishing a Single Program for Community Care ............................... 96

6.3

Process and Organizational Structure Improvements ........................... 100

6.4

Summary of Legislative Proposals ........................................................ 102

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Plan to Consolidate Community Care Programs

7.0

Descriptions of Each Non-Department Provider Program and Statutory


Authority ......................................................................................................... 104

8.0

Appendix ........................................................................................................ 114


8.1

Glossary ................................................................................................ 114

8.2

Acronym List ......................................................................................... 116

8.3

Alignment with Independent Assessment Recommendations ............... 118

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Plan to Consolidate Community Care Programs

Table of Figures
Figure 1: New VCP Report Outline. ................................................................................ 13
Figure 2: Continuum of Care Coordination. .................................................................... 22
Figure 3: Care Coordination Experience Based on Veterans PCP Choice. ................... 24
Figure 4: System of Systems Approach for the New VCP .............................................. 32
Figure 5: High-Performing Network Model...................................................................... 57
Figure 6: Diagram of Medium- and Long-Term Improvements for Health Information
Management .................................................................................................. 71
Figure 7: Phased Approach to the New VCP.................................................................. 74

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Plan to Consolidate Community Care Programs

Table of Tables
Table 1: Impact of the Single Program for Non-Department Care Delivery .................. 35
Table 2: Current-State Eligibility CriteriaHospital Care, Medical Services, and
Dentistry ......................................................................................................... 38
Table 3: Current-State Eligibility CriteriaEmergency Treatment ................................ 39
Table 4: Future-State Eligibility CriteriaHospital Care and Medical Services ............ 42
Table 5: Future-State Eligibility CriteriaEmergency Treatment and Urgent Care ...... 43
Table 6: Impact of the Patient Eligibility Requirements ................................................. 44
Table 7: Referral and Authorization Definitions ............................................................ 45
Table 8: Impact of Authorizations ................................................................................. 47
Table 9: Impact of Billing and Reimbursement ............................................................. 50
Table 10: Impact of Provider Reimbursement Rate ........................................................ 53
Table 11: Key Elements of the High-Performing Network .............................................. 57
Table 12: High-Level Provider Credentialing Standards ................................................. 59
Table 13: Impact of Provider Eligibility ............................................................................ 60
Table 14: Impact of Prompt Payment Compliance ......................................................... 62
Table 15: Impact of Network and Infrastructure .............................................................. 65
Table 16: Current-State Limitations for Health Information Management ....................... 68
Table 17: Near-Term Improvements for Health Information Management ..................... 69
Table 18: Medium & Long Term Improvements for Health Information Management .... 70
Table 19: Impact of Medical Records Management Requirements ................................ 71
Table 20: Alignment of New VCP Functional Areas to Component Systems ................. 73
Table 21: New VCP Transition Risks .............................................................................. 83
Table 22: Estimated Incremental Costs for New VCP System Redesign & Solutions .... 89
Table 23: Estimated Incremental Costs for New VCP Hospital Care and Medical
Services Eligibility Changes ........................................................................... 90
Table 24: Estimated Incremental Costs for New VCP Emergency Treatment Changes. 91
Table 25: Summary of Legislative Proposals................................................................ 102
Table 26: VAs General Contracting Authorities for Health Care .................................. 104
Table 27: VAs Authority to Reimburse for Community Care ........................................ 106
Table 28: VAs Community Care Programs .................................................................. 107

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Plan to Consolidate Community Care Programs

Table 29: VAs Benefit Programs to Provide Services to Veterans, Survivors, and
Dependents .................................................................................................. 108
Table 30: VAs Authority to Furnish Specific Services by Community Providers .......... 109
Table 31: Alignment with Independent Assessment Report Recommendations........... 118

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Plan to Consolidate Community Care Programs

1.0

Executive Summary

The Department of Veterans Affairs (VA) is committed to providing Veterans access to


timely, high-quality health care. In todays complex and changing health care
environment, where VA is experiencing a steep increase in demand for care, it is
essential for VA to partner with providers in communities across the country to meet the
needs of Veterans. To be effective, these partnerships must be principle-based,
streamlined, and easy to navigate for Veterans, community providers, and VA
employees. Historically, VA has used numerous programs, each with their own unique
set of requirements, to create these critical partnerships with community providers. This
resulted in a complex and confusing landscape for Veterans and community providers,
as well as the VA employees that serve and support them.
Acknowledging these issues, VA is taking action as part of an enterprise-wide
transformation called MyVA. MyVA will modernize VAs culture, processes, and
capabilities to put the needs, expectations, and interests of Veterans and their families
first. Included in this transformation is a plan for the consolidation of community care
programs and business processes, consistent with Title IV of the Surface Transportation
and Veterans Health Care Choice Improvement Act of 2015 (also known as the VA
Budget and Choice Improvement Act) and recommendations set forth in the
Independent Assessment of the Health Care Delivery Systems and Management
Processes of the Department of Veterans Affairs (Independent Assessment Report) that
was required by Section 201 of the Veterans Access, Choice, and Accountability Act of
2014 (The Choice Act).
This document provides a plan for how VA could
consolidate all purchased care programs into
one New Veterans Choice Program (New VCP).
The New VCP will include some aspects of the
current Veterans Choice Program (Section 101
of PL 113-146, as amended) and incorporate
additional elements designed to improve the
delivery of community care. The 10 elements of
this plan, as set forth in law, are listed to the
right. With the New VCP as described in this
plan, enrolled Veterans will have greater choice
and ease of use in access to health care
services at VA facilities and in the community.

VA Budget and Choice Improvement Act


Legislative Elements
1.

Single Program for Non-Department


Care Delivery
2. Patient Eligibility Requirements
3. Authorization
4. Billing and Reimbursement Process
5. Provider Reimbursement Rate
6. Plan to Develop Provider Eligibility
Requirements
7. Prompt Payment Compliance
8. Plans to Use Current Non-Department
Provider Networks and Infrastructure
9. Medical Records Management
10. Transition Plan

The New VCP will clarify eligibility requirements, build on existing infrastructure to
develop a high-performing network, streamline clinical and administrative processes,
and implement a continuum of care coordination services. Clear guidelines,
infrastructure, and processes to meet VAs community care needs will improve
Veterans experience and access to health care. VAs future health care delivery

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Plan to Consolidate Community Care Programs

network will address gaps in Veterans access to health care in a simple, streamlined,
effective manner and will continue to support VAs missions of research and education.
VA is continuing to examine how the Veterans Choice Program interacts with other VA
health programs, including the delivery of direct care. In addition, VA is evaluating how
it will adapt to a rapidly changing health care environment and how it will interact with
other health providers and insurers. As VA continues to refine its health care delivery
model, we look forward to providing more detail on how to convert the principles
outlined in this plan into an executable, fiscally-sustainable future state. In addition, we
plan to receive and potentially incorporate recommendations from the Commission on
Care and other stakeholders.
VA anticipates improving the delivery of community care through incremental
improvements as outlined in this plan, building on certain provisions of the Veterans
Choice Program. The implementation of these improvements requires balancing care
provided at VA facilities and in the community, and addressing increasing health care
costs. VA will work with Congress and the Administration to refine the approach
described in this plan, with the goal of improving Veterans health outcomes and
experience, as well as maximizing the quality, efficiency, and sustainability of VAs
health programs.

The Path Forward


The design of the New VCP (Legislative Element 1) is based on feedback from
Veterans, Veteran Service Organizations (VSOs), VA employees, Federal stakeholders,
and best practices. VAs plan centers on five functional areas. Within each functional
area are key points to enable Veterans to receive timely and high-quality health care.
1. Veterans We Serve (Eligibility) This area addresses overlapping community care
eligibility requirements, as directed in Legislative Element 2. Streamlining and
consolidating these requirements will allow Veterans to easily understand their
eligibility for community care and access community care faster. VA and community
providers will have significantly lower administrative burdens, which have often
impeded timely delivery of Veterans care. This area includes the following possible
enhancements:

Establish a single set of eligibility criteria for all community care based on
geographic access/distance to a VA primary care provider (PCP), wait-time for
care, and availability of services at VA.
Expand access to emergency treatment and urgent community care.

2. Access to Community Care (Referral and Authorization) This area addresses


the complicated process of community care referrals and authorizations, as directed
in Legislative Element 3. VA will optimize the referral and authorization systems and

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Plan to Consolidate Community Care Programs

supporting processes, enabling more rapid exchange of information to support timely


delivery of care. This area includes the following possible enhancements:

Streamline business rules in referral and authorization to minimize delays in


delivering care and eliminate unnecessary administrative burdens.
Improve VA visibility into health care utilization in the community.

3. High-Performing Network This area leverages components of existing


non-Department networks and identifies new community partners to build a
high-performing network, as outlined in Legislative Element 8. Addressing issues of
provider eligibility requirements and reimbursement rates, as outlined in Legislative
Elements 5 and 6, will be key to this approach. This area includes the following
possible enhancements:

Develop a tiered, high-performing provider network to better serve Veterans,


consisting of the following categories:
VA Core Network: Includes existing relationships with high-quality health
care assets in the Department of Defense (DoD), Indian Health Service (IHS),
Federally Qualified Health Centers (FQHC), Tribal Health Programs (THP),
and academic teaching affiliates.
External Network: Includes commercial community providers and
distinguishes Preferred providers based on quality and performance criteria.
Move towards value-based payments in alignment with industry trends.
Implement productivity standards to better manage supply and demand.
Develop dedicated customer support to improve Veteran and community provider
experiences.

4. Care Coordination This area focuses on improving medical records management


and strengthening existing care coordination capabilities, as directed by Legislative
Element 9. Improving medical records management will support a high-performing
network and enable better decision making through analytics. It will also support
more effective care coordination and improved Veteran health care outcomes. This
area includes the following possible enhancements:

Offer a continuum of care coordination services to Veterans, tailored to their


unique needs.
Use analytics to improve Veterans health by guiding them to personalized
services and tools (e.g., disease management, case management).
Enable community providers to easily exchange health information with VA.
Design customer service systems to help resolve inquiries from Veterans and
community providers regarding care coordination.

5. Provider Payment This area focuses on improving billing, claims, and


reimbursement processes, as well as Prompt Payment Act (PPA) compliance for
purchasing care, as directed by Legislative Elements 4, 5, and 7. This area includes
the following possible enhancements:

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Plan to Consolidate Community Care Programs

Implement a claims solution which is able to auto-adjudicate a high percentage of


claims, enabling VA to pay community providers promptly and correctly.
Move to a standardized regional fee schedule, to the extent practicable, for
consistency in reimbursement.

The New VCP will use a system of systems approach to enhance these five functional
areas as part of the larger VA health care transformation. This approach stresses the
interactive, interdependent, and interoperable nature of external and internal
components within VAs health care delivery system. The New VCP includes
enhancements to the following systems, which will have a positive impact on VA and
the greater Veterans health ecosystem:

Integrated Customer Service Systems Provide a reliable, easy-to-use way for


Veterans and community providers to get their questions answered, provide
feedback, and submit inquiries.
Integrated Care Coordination Systems Establish a clear process for Veterans to
seamlessly transition between VA and community care, supporting positive health
outcomes wherever the Veteran chooses to receive care.
Integrated Administrative Systems (Eligibility, Referral, Authorizations, and
Billing and Reimbursement) Simplify eligibility criteria so Veterans can easily
determine their options for community care, streamline the referral and authorization
process to enable more timely access to community care, and standardize business
processes to minimize administrative burden for community providers and VA staff.
High-Performing Network Systems Enable the development and maintenance
of a high-performing provider network to maximize choice, quality, and value for
Veteran health care.
Integrated Operations Systems (Enterprise Governance, Analytics, and
Reporting) Define ownership and management of community care at all levels of
VA, local and national, and institute standard metrics to drive high performance and
accountability across facilities.

The New VCP plan envisions a three-phased approach to implement these changes to
support improved health care delivery, as outlined in the Transition Plan (Legislative
Element 10). This will deliver incremental improvements while planning for a future
state consistent with evolving health care best practices. The first phase will include
development of the implementation plan and will focus on the development of minimum
viable systems and processes that can meet critical Veteran needs without major
changes to supporting technology or organizations. Phase II will consist of
implementing interfaced systems and community care process changes. Finally, Phase
III will include the deployment of integrated systems, maintenance and enhancement of
the high-performing network, data-driven processes, and quality improvements.
Executing the New VCP will not be possible without approval of requested legislative
changes and requested budget. The primary objectives of the legislative proposal

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recommendations are to make immediate improvements to community care, establish a


single program for community care, and implement necessary business process
improvements. The budget section of this plan is divided into three parts: (1) System
Redesign and Solutions; (2) Hospital Care and Medical Services, including Dentistry;
and (3) Expanded Access to Emergency Treatment and Urgent Care. System
Redesign and Solutions include enhancements to the referral and authorization
process, care coordination, customer service, and claims processing and payment.
These changes are expected to improve the Veteran experience with community care.
As a result, this may increase Veterans reliance on VA community care, leading to
increased Hospital Care and Medical Services costs. Expanded Access to Emergency
Treatment and Urgent Care is important in providing Veterans with appropriate access
to these services, but is severable from other aspects of the Program and could be
implemented separately.
The incremental costs of the enabling System Redesign and Solutions for the New VCP
are estimated to range between $400 and $800 million annually during the first three
years. VA's community care programs (hospital care, medical services, and long-term
services and supports) prior to the enactment of The Choice Act, cost roughly $7 billion
per year. Continuing the Veterans Choice Program, as amended, beyond its current
expiration will cost approximately an additional $6.5 billion per year, assuming no
changes are made to its current structure (eligibility, referral and authorization, provider
reimbursement, etc.). Improvements to the delivery of community care as described in
this plan would require additional annual resources between $1.5 and $2.5 billion in the
first year and are likely to increase thereafter. The proposed expanded access to
emergency treatment and urgent care requires an additional estimated $2 billion
annually. Refer to the estimated costs and budgetary requirements (Section 5) and
legislative proposal recommendations (Section 6) for additional information.
The estimated costs reflected in this report represent the funding required to maintain
VAs delivery of community care at current levels, as well as incorporating the
considerations outlined in this plan.
VA cannot reach the future state alone. Ongoing partnership with Congress will be
critical to addressing the budgetary and legislative requirements needed for this
important transformation, including outstanding decisions on aspects related to
sustainability and cost-sharing. The support and active participation of Congress,
Federal partners, VA employees, VSOs, and other stakeholders are necessary to
achieve more efficient, effective, and Veteran-centric health care delivery.

Conclusion
Transformation of VAs community care program will address gaps in Veterans access
to health care in a simple, streamlined, and effective manner. This transformation will
require a systems approach, taking into account the interdependent nature of external
and internal factors involved in VAs health care system. MyVA will guide overall

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Plan to Consolidate Community Care Programs

improvements to VAs culture, processes, and capabilities and the New VCP will serve
as a central component of this transformation. The successful implementation of the
New VCP will require new legislative authorities and additional resources and will
position VA to improve access to care, expand and strengthen relationships with
community providers, operate more efficiently, and improve the Veteran experience.

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Plan to Consolidate Community Care Programs

2.0

Purpose of the Report

Each section of this report (Figure 1) directly addresses the legislative elements set
forth in the VA Budget and Choice Improvement Act, Plan to Consolidate Care in the
Community Programs of the Department of Veterans Affairs to Improve Access to Care,
in the VA Budget and Choice Improvement Act and discusses in detail the key
enhancements that will eventually shape the future of VA health care delivery.

Figure 1: New VCP Report Outline

Introduction: The introduction outlines the future of VAs health care delivery and
includes the stated objectives of the New VCP in the larger context of the VA
delivery system, including enhancements to care coordination, and how these
enhancements align with MyVA.

Plan to Consolidate Community Care Programs The New VCP (Legislative


Element 1): Plan to consolidate and streamline existing programs into one
community care program implemented locally with national oversight. Outlined
below are proposals to establish the following:
- Patient Eligibility Requirements (Legislative Element 2): Define a single set of
eligibility requirements for the New VCP.
- Authorizations (Legislative Element 3): Streamline the complex referrals and
authorizations process currently required for Veterans to access non-VA care.
- Billing and Reimbursement (Legislative Element 4): Improve claims processing
to efficiently reimburse community providers.
- Provider Reimbursement Rates (Legislative Element 5): Standardize
overlapping and disconnected fee schedules.

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Plan to Consolidate Community Care Programs

Provider Eligibility Requirements (Legislative Element 6): Identify provider


eligibility requirements and structure the high-performing network.
Prompt Pay Act Compliance (Legislative Element 7): Design systems to
address payment backlogs and comply with the PPA.
Utilizing Current Non-VA Networks and Infrastructure (Legislative
Element 8): Strengthen existing provider relationships and create new
relationships through simplified provider agreements and contracts.
Medical Records Management (Legislative Element 9): Develop a health
information environment that is electronic, secure, efficient, effective,
Veteran-centric, and standards based.
Transition Plan (Legislative Element 10): Identify a three-phased approach to
transition to the New VCP, including requirements of the five systems identified
and associated risks, timeline, milestones, and estimated costs for
implementation, outreach, and training.

Estimated costs and budgetary requirements: Provide the estimated range of


costs and budgetary requirements necessary for VA to successfully implement the
New VCP plan.

Legislative proposal recommendations: Provide any recommendations for new


legislative proposals necessary for VA to successfully implement the plan.

Description of each non-Department provider program and statutory authority:


Provide a description of each non-VA provider program and the respective statutory
authority for each.

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Plan to Consolidate Community Care Programs

3.0

Introduction

VA is committed to providing Veterans accessible, timely, and high-quality care with the
utmost dignity and respect. At the heart of this mission is a commitment to improving
performance, promoting a positive culture of service, increasing operational
effectiveness and accountability, advancing health care innovation through research,
and training future clinicians.
Health care delivery models must adapt and evolve to meet the needs of patients.
Overall, the U.S. health care system is changing significantly with regard to the types of
care demanded and the way patients seek care. New technologies are drastically
changing how patients access care and how providers and patients interact.
Innovations in precision medicine, telehealth, value-based care models, genomics, and
overall operational efficiency represent only some of the trends in U.S. health care over
the last several years.
VA is evolving to meet the distinct needs of Veterans, driven by aging and an increased
number returning from war with mental and physical conditions unique to service, 1 while
also adapting to broader health care trends. Over the last several decades, VA has
seen an increase in demand for primary and preventive care and a decrease in demand
for hospital-centric inpatient care. In 2016, VA estimates that there will be more than
101million outpatient visits annually, an increase of 2.8 million visits per year from
2015. 2 Furthermore, the number of women Veterans requesting health care from VA
has increased by 80 percent over the last decade, meaning VA is experiencing a
greater demand for care and services that have not been traditionally provided at VA
facilities (e.g., obstetrics and mammography). The lack of available services at VA
facilities means that women Veterans must seek community care. In fact, women
Veterans are more than twice as likely as men to receive community care. 3
As the health care landscape changes, VA understands that its health care delivery
system must also change to better meet the evolving needs of Veterans. In August
2014, Congress enacted The Choice Act, which required VA to establish the Veterans
Choice Program to address VAs health care access challenges. The Veterans Choice
Program became an additional method for VA to purchase community care, but added
complexity and confusion for Veterans, VA staff, and community providers.

The Critical Need for Military & Civilian Mental Health Professionals Trained to Treat Post Traumatic
Stress Disorder & Traumatic brain Injury. http://www.apa.org. Accessed October 5, 2015.
http://www.apa.org/about/gr/issues/military/critical-need.aspx.
2 United States. Cong. Senate. Committee on Appropriations Subcommittee on Military Construction,
Veterans Affairs, and Related Agencies. Budget Request for Fiscal Year 2016, Apr. 21, 2015. 114th
Cong. 1st sess. Washington: GPO, 2005 (statement of The Honorable Robert A. McDonald, Secretary,
Department of Veterans Affairs).
3 Sourcebook Vol. 3 - Part 4: Non-VA (Fee) Medical Care Utilization, FY12

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VAs future health care delivery system must address Veterans access to health care in
a simple, streamlined, and effective manner. Veterans should receive uniformly highquality care, whether at VA or in the community. The future VA health care delivery
system must operate more efficiently, better adopt technological advances, and develop
and maintain relationships with strategic partners to support an equitable experience
inside and outside of VA. To reach this desired state, VA plans to use a system of
systems approach that will address the enterprise-wide challenges in meeting the
unique needs of Veterans.

3.1

Stakeholder Feedback

VA leadership engaged a variety of stakeholders to inform the future of VA health care


and the development of a single community care program. VA gathered insights from
Veterans, Veterans Service Organizations (VSOs), VA leaders, staff and clinicians,
Federal and academic partners, Tribal health partners, Congressional Committee staff,
and health care industry leaders on the new community care model. The feedback
collected was largely consistent with the Independent Assessment Report (refer to the
Appendix for additional information) that provided recommendations focused on
streamlining the purchase of community care. 4 These insights informed the vision for
VAs health care delivery system and the plan for the New VCP.
VSOs: VSOs emphasized the need for Veterans choice in how and where Veterans
receive care. Other key themes include:

Continue to provide a unique environment and culture for Veterans health care
Recognize that some Veterans are willing to travel farther to see their VA provider
Clarify processes for accessing community care, as current processes are confusing
Address concerns that the current VA provider system would be underfunded to
purchase community care
Be the face of care coordination for Veterans
Streamline emergency treatment regulations, processes, and procedures, which are
complex, inconsistently applied across Veterans Health Administration (VHA), and
cause significant confusion for VA staff, Veterans, and community care providers

VA Staff and Clinicians: VA staff and clinicians work hard to serve Veterans every
day; however, they need additional support. Feedback from the field identified the
following themes:

Retain elements of the non-VA care program that worked well and relationships that
were effective prior to the Veterans Choice Program and can be used as best
practices

VA and Congress should articulate a clear strategy governing the use of purchased care. Independent
Assessments C. Care Authorities

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Improve efficiency/timeliness of business processes and clinical pathways to support


Veterans to successfully connect to community care
Simplify and consolidate various programs to reduce confusion
Increase staffing and dedicate VA employees to the coordination of community care
Implement technologies to replace manual processes and increase information
sharing
Establish quality metrics/quality review processes for care delivered in the
community

Federal Partners: Discussions with DoD, OMB, agencies of the Department of Health
and Human Services (HHS), including the Centers for Medicare and Medicaid Services
(CMS), the Health Resources and Services Administration (HRSA), and the IHS yielded
the following themes:

Partner to deliver health care services, reducing redundancies in Federal health


services and increasing access
Advance new care models and information sharing
Work together to continue leading in interoperability and care coordination

Tribal Consultation: Tribes from around the country were given the opportunity to
provide feedback about the role of IHS and THP in the VA health care system, as well
as VAs efforts to streamline the provision of non-VA care to Veterans. Responding
tribes indicated the following:

Strong support for the inclusion of IHS and THP as key partners in VAs community
network.
Maintain and strengthen the current agreements between VA, the IHS, and THPs.
Interest from IHS and THPs in potentially serving non-Native Veterans.

Health Care Industry Leaders: Leaders from across the health care industry, focusing
on health plan capabilities and integration with a provider organization, raised the
following themes regarding best practices and opportunities for a future VA community
care program:

Adopt best practices in clinical and administrative decision making by using data on
the needs of Veterans and metrics on the quality of providers
Build a sound technology infrastructure and utilize new technologies and predictive
analytics to optimize health outcomes and enhance Veterans experience
Lead in the field of care coordination
Provide the care and services Veterans require through a high-performing network

Along with extensive input from across VA, these stakeholders helped identify key
requirements for the future of VA health care, of which the New VCP is one component.

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3.2

Future of VA Health Care

As the health care landscape and the needs of Veterans change, VAs health care
delivery model must also change. Historically, VAs identity has been a hospital-based
provider organization. This delivery model is evolving into team-based care delivered in
a variety of settings, including virtual- and home-based care. Simultaneously, VA is
increasingly becoming a larger purchaser of care, in addition to being a provider. VA
will focus on the following set of guiding principles to direct the evolution of VA health
care delivery:
Invest in and grow VAs core competencies. In a transformation such as this,
organizations must make decisions about where to invest resources. No organization
can excel at every capability; high-performing organizations define their core
competencies and excel at those. Service delivery systems designed around core
competencies distinguish organizations from others and provide the highest potential
value to their customers. VA establishes a relationship with Veterans as they transition
out of military service. Unlike commercial health plans, where beneficiaries change
plans periodically and disrupt continuity of care, Veterans are Veterans for life. This
transformation is both a unique opportunity and responsibility for VA to address
Veterans health care more holistically. As VA continues to optimize its health care
delivery system, it is important to continue to focus on areas of critical need to Veterans,
as well as where there are gaps in private sector care (e.g., service-related injuries,
traumatic brain injuries (TBI), post-traumatic stress disorder, and integrated mental
health).
Maintain a high-performing network to deliver care. A high-performing network
refers to an ecosystem of health care providers that optimize the health of beneficiaries
and operational efficiencies. High-performing networks deliver patient-centered care,
are comprised of high-performing providers, monitor quality, incentivize clinicians
through innovative reimbursement models, use
High-performing Network Enablers
data to adapt services, and create a better
environment for customers. High-performing

Delivery of high-quality care

Payment and quality improvement


networks are enabled by tools and practices that
incentives
drive efficiencies, cost savings, and customer

Performance and
experience. 5 As part of a high-performing network,
outcomes-based metrics

Interoperable health information


VA will identify and focus on core clinical
technology platforms
competencies and will partner with community

Team-based care coordination


providers to deliver high-quality, complementary
services. 6

American Medical Group Association, Six Characteristics of High-Performing Health Systems


Systematically study opportunities to improve access to high-quality care through use of purchased
care. Independent Assessment Report Section B. Health Care Capabilities.

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Deliver personalized, proactive, and patient-driven health care. Delivering


Veteran-centric care requires sensitivity to the Veteran culture and creation of care
plans tailored to their specific health needs. While VA providers are familiar with the
Veteran culture, community providers may need additional education and support
through training and decision support tools. Within VA, information systems will allow
clinicians, Veterans, their families, and caregivers to identify health goals and track
effectiveness of interventions on clinical, social, and behavioral determinants of health.
By delivering personalized, patient-driven care, VA will support holistic care, increase
Veteran participation in health care, and provide tailored therapies unique to the needs
of each Veteran, their family, and their caregivers.
Use metrics and data analytics to drive improvement. Providing care through a
high-performing network is a data-intensive undertaking requiring a system of systems
approach. From a clinical care perspective, monitoring quality and value of care
requires the ability to report outcomes measured through the exchange and aggregation
of data. From a clinical capacity perspective, VA will track utilization, provider
productivity, and quality to understand when and where Veterans need care and to
balance resources as those needs change. From a process improvement perspective,
workflows and systems will be designed and evaluated to promote the best experience
for Veterans, VA staff, and community providers. From a quality improvement
perspective, interventions to improve care will be evaluated to determine their efficacy.
Data-driven decision making requires a robust technology infrastructure that allows for
appropriate data capture, exchange, transparency, and analysis.
Focus on research and education missions. VA has a long history of research and
medical education. These missions are integral to providing high-quality care to
Veterans now and in the future. Clinicians trained in VA facilities have experience
treating Veterans and a deep understanding of Veterans health. Whether their clinical
career is in a VA facility or in the community, these trainees are the future providers of a
high-performing network. Similarly, VA supports research that focuses on Veteranspecific health needs to understand and improve treatment.
Use innovative technologies and value-based care models to optimize health
outcomes. The health care landscape continues to evolve. Technology continues to
push the boundaries of health and wellness. As an example, Telemedicine Intensive
Care Unit (TeleICU) programs allow remote monitoring of patients by providing
real-time, high-quality data to an intensivist across the street or the country. This
increases the capacity of a single intensivist to care for a panel of patients and allows
patients to be in intensive care close to family support, even if an on-site intensivist is
not available. In addition to advancements in technology, CMS is driving innovation in
how health care is paid for by sponsoring pilots for a variety of value-based care
models, identifying how organizations can work together to provide high-value care to
patients. Innovation in care delivery models, technology, and the combination of the
two will continue to change the face of health care. VA must continue to adapt to the

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Plan to Consolidate Community Care Programs

evolving health care landscape and adopt new technologies, but should also recognize
that current methods for measuring success in this area may be limited.
Consistent with the Independent Assessment Report, VA plans to employ a system of
systems approach for the development, deployment, long-term oversight, and
coordination of health care delivery. 7 This is defined as The design, deployment,
operation, and transformation of metasystems that must function as an integrated
complex system to produce desirable results. These metasystems are themselves
composed of multiple autonomous embedded complex systems that can be diverse in
technology, context, operation, geography, and conceptual frame. 8 This recognizes
that systems are constructed from components and optimization of a single component
may negatively affect others.
In this report, we identify requirements of five systems necessary to VA health care and
the New VCP:
1. Integrated Customer Service Systems
2. Integrated Care Coordination Systems
3. Integrated Administrative Systems (Eligibility, Patient Referral, Authorization, and
Billing and Reimbursement)
4. High-Performing Network Management Systems
5. Integrated Operations Systems (Enterprise Governance, Analytics, and Reporting)
Some components of these systems already exist at VA. For these systems to work
together seamlessly with care provided at VA and non-VA facilities, they must be
designed as a system of systems. From that perspective, while the elements of this
report focus on the purchase of community care, the development of a high-performing
network cannot occur without addressing both care delivery by VA providers and care
purchased in the community. Therefore, in addressing systems supporting the
purchase of community care, VA must ensure that these systems are fully integrated
with those supporting Veterans care within VA.
Care coordination is critical to support the delivery of VA health care as Veterans
access care at VA facilities, virtually, and in the community. The relationship of the
Veteran (and caregivers) to his or her primary care team is central to coordination.
Care coordination, however, is not a one-size-fits-all model; it occurs on a spectrum. As
a Veterans needs evolve, VA will need to tailor care coordination to each situation.

Independent Assessment Report


Keating, C., Rogers, R., Unal, R., Dryer, D., Sousa-Poza, A., Safford, R., Peterson, W. and Rabadi, G.
(2003) System of systems engineering, Engineering Management Journal, Vol. 15, No. 3, pp. 3645.
8

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Plan to Consolidate Community Care Programs

3.3

Care Coordination

VA can be a leader in care coordination. While this is a broad term with a variety of
interpretations in health care, the Agency for Healthcare Research and Quality (AHRQ)
states that, care coordination involves deliberately organizing patient care activities and
sharing information among all of the participants concerned with a patient's care to
achieve safer and more effective care. This means that the patients needs and
preferences are known ahead of time and communicated at the right time to the right
people, and that this information is used to provide safe, appropriate, and effective care
to the patient. 9 The goal of care coordination is to meet patient needs and deliver highquality, high-value care from the perspectives of the patient and family, provider team,
and the health system. Care coordination should improve health outcomes, prevent
gaps caused by transition of setting or time, and support a positive and engaging patient
experience.
Operationally, care coordination is a team-based activity that includes the patient,
family, caregivers, staff, and clinicians. Each part of the team has different needs for
services and information (clinical and administrative) during a transition of care, such as
referral to a specialist, hospital discharge, or a period of time between clinical visits. In
the example of a referral, a PCP and a patient decide to seek the input of a specialist on
a specific condition. The patient and caregivers need to know how to choose a
provider, what to do before the visit, when to go, and how to follow up appropriately.
The primary care team needs to communicate clinical information to the specialist;
understand when the visit has occurred; what the diagnosis was; and how to support
any subsequent care plan. VA staff need to know how to help patients and caregivers
to schedule and attend the appointment and how to direct appropriate information to the
team. For this transition to be seamless, all parties need access to systems that supply
accurate, timely information, workflows that address the needs of the team members,
and metrics to understand the success of these interactions. As a result, care
coordination is complex and information intensive, requiring a cohesive approach.
While this is an area of intense focus for the health care industry, the private sector has
not converged on a standardized care coordination model. This makes care
coordination an opportunity for VA to be a leader in developing innovative solutions with
strategic partners within the high-performing network.
For all Veterans, care coordination will fall along a continuum of intensity, from basic
care coordination or patient navigation to care/disease management to case
management, as illustrated in Figure 2. This continuum is influenced by a variety of
factors: the complexity of clinical conditions, Veterans preference around engagement,
PCP choice, and care setting. VA currently offers many diverse care coordination
programs that can be difficult to understand and navigate. VA plans to consolidate these
9

http://www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/index.html (accessed
September 22, 2015)

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Plan to Consolidate Community Care Programs

programs into an integrated, enterprise-wide model implemented locally. As care


coordination matures at VA, it will be provided as a service to community providers who
care for Veterans in need of more intensive coordination. The impact of this
coordination continuum is to enable Veterans receive the type of care management and
coordination necessary to achieve positive health care outcomes.

Figure 2: Continuum of Care Coordination

Basic Care Coordination/Patient Navigation


Basic care coordination involves the coordination of appointments and scheduling for
Veterans and their caregivers, enabling them to know who to see, when to go, and why.
Most Veterans will utilize this level of care coordination and patient navigation. This
requires support from staff responsible for medical data integration, referral
coordination, and appointment scheduling assistance. This also includes second-line
support available for administrative questions and self-service options, such as a
web-based portal or mobile apps, to engage Veterans in their wellness and allow them
to quickly complete transactions. 10 Patient navigation is an intervention or a specific
person who helps Veterans access care. These services are aimed at helping Veterans
who have multiple comorbidities and providers, but do not need complex care
coordination.

10

Independent Assessment Report H. Health Information Technology. VA should explicitly identify mobile
applications as a strategic enabler to increase Veteran access and satisfaction and help VHA transition to a datadriven health system.

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Plan to Consolidate Community Care Programs

Care/Disease Management
Care management is the oversight and management of a comprehensive care plan for
a population of patients with specific diseases. Care management facilitates the
delivery of clinically recommended care to optimize health outcomes for Veterans and
avoid gaps or duplications in care. Veterans in need of care management will be
identified through clinical information and PCP referrals. This program will allow VA to
proactively conduct Veterans outreach, encourage healthy behavior, advance clinical
best practices, provide disease education, and engage Veterans in self-management.
As a result, VA will be in a position to better address care needs earlier and support
positive long-term outcomes.

Case Management
Case management is a specialized and highly skilled component of care coordination.
Case management emphasizes a collaborative process that assesses, advocates,
plans, implements, coordinates, monitors, and evaluates health care options and
services, so they meet the unique needs of the complex patient. Case management is
the most intensive level of care coordination. A multidisciplinary team manages care for
Veterans with the most catastrophic and complex conditions (e.g., TBI and spinal injury)
and coordinates treatments across multiple providers and venues of care. Dedicated
case managers use a holistic approach to coordinate and manage Veteran health care,
including consideration of psychosocial factors that affect care. Innovation in this area
can include novel methods for the integration of housing assistance with substance
abuse and mental health care for homeless Veterans.
Veterans who require case management often have a family member or caregiver who
assists them with a variety of personal care activities, ranging from assistance in
arranging and coordinating care, to assistance with Activities of Daily Living (ADL)
and/or Instrumental ADL, or keeping them safe in the community. Support of family
members and friends who serve as caregivers is essential in order for Veterans to
achieve their treatment goals. Caregiver training and support programs also will be
available to family members and caregivers of Veterans who are being treated for
complex conditions, allowing Veterans to obtain the comprehensive, integrated support
they need.

Care Coordination Enablers


Robust care coordination, for any of the three levels on the continuum, requires a strong
health IT platform and a highly trained team. VAs future health IT platform will perform
the following functions: maintenance of a care plan; a user-friendly interface for
Veterans and caregivers to see their information; and an accurate, timely information for
providers. Needs will be tracked in the care plan and will include social and behavioral
determinants of health. Patient-facing and telehealth technologies will allow Veterans to
update their health and needs status in addition to the ability to view their health data
and care plan. Providers will use VAs medical records exchange to support health

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Plan to Consolidate Community Care Programs

information transactions and care teams will use the platform to support Veterans in
their health care experience. Through team management, aspects of patient
navigation, care management, and case management can address short-term issues or
issues over extended periods of time.
In addition to individual Veterans and their care teams, information and coordination can
also support population management. Population management is a data-driven
process for proactively defining a cohort of patients who might benefit from a health
care plan or intervention aimed at primary or secondary prevention. This allows care
teams to offer the right service to the right Veteran at the right time.

Care Coordination Relationships


The relationship between a Veteran and their primary care team is the foundation of
high-quality health care. Veterans will access care coordination differently based on
where they choose to receive their primary care. Veterans with a VA PCP will have the
support of the Patient-Aligned Care Team (PACT), VAs patient-centered medical home,
to deliver basic care coordination/patient navigation. Veterans with a community PCP
will have basic care coordination/patient navigation through their PCPs associated care
team. As team-based care models mature and the New VCP evolves, VA will
increasingly partner with community PCPs who have adopted patient-centered medical
home models. All Veterans, whether they have a VA or community PCP, will have
access to VA support, as needed, and to disease and care management programs.
Figure 3 outlines two scenarios of how PCPs and Veterans will partner for care
coordination relationships.

Figure 3: Care Coordination Experience Based on Veterans PCP Choice


Using a system of systems approach, VA will ensure care coordination is a seamless
and effective tool for Veterans and their families, VA, and community providers to create
a positive health care experience.

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Plan to Consolidate Community Care Programs

3.4

Alignment with MyVA

The MyVA Transformation Plan will modernize VAs culture, processes, and capabilities
in order to put the needs, expectations, and interests of Veterans first. It will improve
the Veteran experience by empowering employees to deliver excellent customer
service, improving or eliminating processes that
MyVA Priorities
impede customer service, and rethinking how to
become more Veteran centric. 11 The five

Improving the Veteran Experience

Improving
the Employee Experience to
priorities of MyVA align directly with the
Better Serve Veterans
components of the New VCP.

Increasing Internal Support Services

Establishing a Culture of Continuous

Improvement
Improving the Veteran Experience. VA exists

Enhancing Strategic Partnerships


to serve Veterans. The service provided to
Veterans should be world class and leave
Veterans satisfied with their experience, including the care they receive, the manner in
which they receive it, and the ease of understanding that care. In designing the future
of VA health care, emphasis will be put on understanding how Veterans experience
their care, at VA or in the community, and how it can be improved to achieve health
outcomes. The New VCP will have dedicated customer service representatives with
information to help Veterans access care, high-quality care coordination to help
Veterans navigate transitions between providers and services, and access to a
high-performing network of providers.

Improving the Employee Experience to Better Serve Veterans. Providing VA


employees with easy access to information and tools that will better equip them to
answer Veterans questions and consistently provide correct information. Automation of
many business processes and removal of unnecessary steps will allow employees to
focus on Veterans needs rather than manual tasks. Formalized training programs will
ensure employees have the right knowledge of the New VCP to support Veterans and
providers.
Improving Internal Support Services. Foundational process improvements also will
be made to internal support services. Referrals, authorizations, and claims will be
processed efficiently and transparently by appropriate experts within VA, reducing
administrative burden and allowing VA staff to focus on health care delivery. Call
centers for Veterans and community providers will be available along with a provider
health information gateway for efficient information exchange.
Establishing a Culture of Continuous Improvement. Maintaining a culture of
continuous improvement will save time for VA staff and facilitate more rapid access to
7 VA Announces Single Regional Framework under MyVA Initiative, January 26, 2015
(http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2672)

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Plan to Consolidate Community Care Programs

care and improve the experience of Veterans. This culture is key to a system of
systems approach and will require VA to simplify processes and reduce waste. Data
analytics are required for this type of improvement, such as identification of the highest
performing community providers or outreach to Veterans who would benefit from higher
intensity care coordination. Continuous improvement aligns VA with health plan best
practices and will be necessary for ongoing PPA compliance.
Enhancing Strategic Partnerships. Enhancing strategic partnerships will allow VA to
provide higher-quality care to Veterans and better manage costs. VA will continue to
strengthen relationships with: DoD, IHS, THP, FQHC, and academic teaching affiliates.
VA will also identify and engage high-quality community providers in an external
network to provide Veterans with the best possible health care. Finally, VA will work
with CMS and Accountable Care Organizations (ACOs) to evolve toward value-based
care models. This will support VAs high-performing network.

3.5

Impact to Veterans, Community Providers, and VA

The design of the future VA health care delivery system, including the New VCP, is
intended to advance Veterans well-being and support their caregivers, community
providers, and VA, as a whole, through improvements in clinical care, business
processes, and customer service.
Impact to Veterans. Veterans should have access to the best care anywhere through
a high-performing network that preserves a Veterans choice in choosing community
providers. Access to emergency treatment will be expanded and Urgent Care needs
will be addressed. VA will actively engage Veterans, their families, and caregivers in
their health care choices, providing innovative tools to help Veterans stay healthy and
manage chronic conditions, as well as connect with their care team in person or
virtually. Enhanced care coordination will improve Veterans health outcomes and
improve health care services received by Veterans. The consolidated community care
program will have clear eligibility criteria, streamline referral and authorization
processes, make customer support available when needed, and eliminate ambiguity
around eligibility and personal financial obligations for care. While providing clarity,
eligibility criteria will also be flexible enough to respond to unique needs of Veterans,
such as excessive burden in travelling to a VA facility or the clinical need to be seen by
a provider in a timeline that is shorter than the VA wait-time standard for a particular
service. Veteran eligibility for community care will be evaluated over time depending on
health care innovations and changes to the Veteran population, such as the increasing
number of women Veterans.
Impact to Community Providers. With the enhancements of the New VCP,
community providers will want to work with VA. A single, efficient referral process will
reduce confusion in care transitions and expedite the process of getting Veterans the
care they need. Increasing health IT adoption and interoperability standards will provide

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Plan to Consolidate Community Care Programs

easy access to clinical information, simplifying care coordination between VA and


community providers. The New VCP focuses on operational efficiencies, including
standardized billing and reimbursement, and geographically adjusted fee schedules tied
to Medicare, as appropriate, to make it easier and more appealing for community
providers to work with VA. Additionally, improvements in how VA processes claims will
enable VA to reimburse community providers in a timely fashion. VAs purchasing
power for supplies, such as pharmacy and durable medical equipment (DME), will allow
community providers easy access to items critical to Veterans care, reducing their
administrative burden.
The New VCP will allow VA to establish clear and straightforward participation
agreements with community providers, which will have a positive impact on the number
of providers joining the network. Increasing the number of providers in the network
should ultimately improve access, decrease wait-times. Over time, VA will work with
community providers on value-based payment models to provide the highest quality
care to Veterans.
Impact to VA. The New VCP will allow VA to resolve issues in the current Veterans
Choice Program and strengthen internal capabilities for the future state of VA health
care delivery. VA plans to consolidate multiple community care programs into a single,
simplified program with clear guidelines, infrastructure, and processes. VA will work to
improve business processes that support clear and consistent Veteran and provider
eligibility, referral and authorization, billing and reimbursement, provider reimbursement
rates, PPA compliance, medical records management, and care coordination. VA
should see an increase in efficiency and processing speed through claims auto
adjudication that will minimize errors due to manual processing.

3.6

Implementation Dependencies and Requirements

Achieving the enhancements discussed above and arriving at the future state of VA
health care will not happen overnight. Without the necessary resources, authorities,
and legislation, the New VCP will not succeed. The transformative changes set forth in
this plan will require an investment of time and resources to enable Veterans to
effectively access community care. VA will need the ability to evaluate its physical
footprint to support appropriate resource allocation. In addition, funding and budgetary
relief is requested to supplement the capital investment required to build and enhance
existing systems; details are included in the cost and budget portion of this report
(Section 5). VA also requires the necessary authorities to consolidate its programs and
design the system of systems that will be the future of VA health care delivery. Specific
legislative proposal recommendations are included in this report (Section 6). VA will
work closely with members of Congress and their staff on legislation to establish the
New VCP and welcomes discussion on how these changes will affect Veterans.

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Plan to Consolidate Community Care Programs

4.0
4.1

Plan to Consolidate Community Care Programs


Element 1: Single Program for Non-Department Care Delivery

Legislation
A standardized method to furnish such care and services that incorporates the
strengths of the non-Department provider programs into a single streamlined program
that the Secretary administers uniformly in each Veterans Integrated Service Network
(VISN) and throughout the medical system of the VHA.

Summary

Key Activities

In order to provide Veterans with more intuitive,


convenient, and timely access to community care,
VA plans to consolidate and simplify methods for
purchasing care under a single program called the
New VCP. This change responds directly to the
recommendation to streamline programs for
providing access to purchased care and use them
strategically to maximize access contained in the
Independent Assessment Report. 12

Consolidate existing community care


programs
Create a governance structure to
integrate community care with VA
provided care at the local and national
level
Use a system of systems approach to
design the future state

VA considered the larger VA health care system and the environment of health care as
a whole when consolidating community care programs. The New VCP will have a
single set of eligibility criteria for Veterans seeking community care. This program will
also improve the Veteran experience by providing a level of care coordination that
meets the needs of the individual Veteran. It will establish a high-performing provider
network, structured with tiers that will allow VA to preserve existing relationships with
Federally funded partners and academic teaching affiliates, while increasing access to
high-quality community providers. It will also implement a consistent approach for
accessing care (referrals and authorizations), sharing medical information, and
processing provider payment (claims). Over time, existing mechanisms for purchasing
care will either be folded into the New VCP or phased out.
To support a consistent and positive Veteran experience, VA plans to implement a
streamlined system of systems approach for the New VCP that will be integrated with
the VAs internal health care system. The component systems for the New VCP are:
1) Integrated Customer Service Systems, 2) Integrated Care Coordination Systems,
3) Integrated Administrative Systems (Eligibility, Patient Referral, Authorizations, Billing,
and Reimbursement), 4) High-Performing Network Systems, and 5) Integrated
Operations Systems (Enterprise Governance, Analytics, and Reporting).

12

Independent Assessment Report Section B. Health Care Capabilities

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Plan to Consolidate Community Care Programs

This program represents a significant organizational change for VA. It will require
detailed planning, system and process redesign, and implementation, as well as action
by Congress. Accordingly, VA has developed a transition plan that will be implemented
over three phases (see Legislative Element 10Transition Plan). This phased
approach will allow VA to make necessary changes to meet the care needs of Veterans
in the short term, while simultaneously designing and implementing an integrated
system that supports the long-term vision for VA health care.
Programs, such as the Civilian Health and Medical Program of the VA (CHAMPVA),
Camp Lejeune Family Member Program, Spina Bifida Health Care Benefits Program,
Children of Women Vietnam Veterans (CWVV) Health Care Program, and the Foreign
Medical Program (FMP), will continue to exist as they do today because their eligible
populations do not typically receive care at VA facilities and foreign care requires a
specialized set of administrative processes. VA will, however, use standardized
systems established for the New VCP to promote operational efficiency for all
community care programs.

Background
Representative Community Care

Historically, to meet the evolving needs of


Programs for Veterans will be
Veterans, additional methods for purchasing nonconsolidated into the New VCP
VA care were created rather than augmenting or
Veterans Choice Program
enhancing existing programs. These methods
Patient-Centered Community Care
typically served a specific population (e.g., Project
(PC3)
Project ARCH
Access Received Closer to Home (ARCH) to meet
Fee Basis Care
geographic access challenges) or responded to a
Dialysis Contracts
specific need in the population (e.g., Dialysis
Retail Pharmacy Network Contracts
Contracts). Many of these methods have
Emergency Care (38 U.S.C. Sections
1703, 1725, and 1728)
overlapping or inconsistent eligibility criteria,

Federally funded partners (DoD, IHS,


employ multiple processes for the same activity
THP, FQHC) and academic teaching
(e.g., claims management), and implement varying
affiliates
reimbursement models. These fragmented
methods create a community care experience for
Veterans that is not consistent or well integrated with the larger VA health care system.
This approach is also inconsistent with best practices in other Federal programs and
private industry for purchasing community care. A best practice is to design a single,
adaptable product for each population (e.g., the employees of a large company), while
establishing a flexible operational foundation for consistent product delivery across
patient populations and provider networks.

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Plan to Consolidate Community Care Programs

Current State
VA has a number of statutory authorities, programs, and other methods for purchasing
community care, as outlined in the Descriptions of Each Non-Department Provider
Program and Authority section of this report. As mentioned above, the various methods
for receiving community care have conflicting structures, responsibilities, ownership,
and management, with different application at the local and national levels. This leads
to inconsistencies in their use and implementation across facilities, from Veteran to
Veteran, and from one episode of care to another. Ultimately, the multiple methods and
overlapping roles, responsibilities, and processes lead to inefficient execution and
significant confusion among Veterans, community providers, VA providers, and staff. In
addition, many of these methods have differing requirements and processes for key
components, including, but not limited to, eligibility criteria and eligibility determinations;
referrals and authorizations; provider credentialing and network development; care
coordination (including medical records management); reimbursable out-of-pocket
expenses (e.g., urgent/emergent outpatient prescriptions); and claims management.
This challenge is exacerbated by the inconsistent level of customer service available to
Veterans and community providers, creating difficulties in resolving inquiries, appeals,
and grievances. Finally, it is difficult to evaluate which programs are operating well
because performance data is not consistently collected.

Future State
The New VCP plans to consolidate existing methods for community care into a single,
efficient program integrated into the broader context of VAs health care system.
A Veteran-centric design will provide straightforward eligibility criteria and a single set of
clinical and administrative systems and processes, allowing Veterans choice in
providers and effective care coordination. This addresses the Independent Assessment
Report recommendation that VA and Congress should eliminate inconsistencies in
current authorities and provide VA with more flexibility to implement a purchased care
strategy. 13 The New VCP will honor VAs special relationships with strategic partners,
such as DoD, IHS, THP, FQHC, and academic teaching affiliates.
The Program also will involve the design and implementation of the five component
systems that will integrate into the system of systems for the New VCP. The
component systems of the New VCP are 1) Integrated Customer Service Systems,
2) Integrated Care Coordination Systems, 3) Integrated Administrative Systems
(Eligibility, Patient Referral, Authorization, and Billing and Reimbursement),
4) High-Performing Network Systems, and 5) Integrated Operations Systems
(Enterprise Governance, Analytics, and Reporting. This section provides a high-level
description of the consolidation of existing methods for purchasing community care as
well as each of the component systems and processes for the New VCP. Additional
details on many aspects of the program are contained later in this report.
13

Independent Assessment Report Section C. Care Authorities

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Plan to Consolidate Community Care Programs

Consolidation of Existing Methods for Purchasing Community Care


Some existing methods for purchasing Veteran community care will be phased out,
while other methods, particularly those that provide VA with access to provider networks
and special partnerships (e.g., federally funded and academic teaching affiliates) will
continue in the New VCP. Consolidating these methods under a single program will
enable a seamless experience for Veterans and community providers. In the short
term, VA will preserve the ability to execute one-time referrals when a network provider
is not available using provider agreements as described in the Legislative Proposal
Recommendations section of this report. However, these referrals will decrease over
time as VAs provider networks become more robust.
Agreements with Federal and federally funded partners and with academic teaching
affiliates will continue to form a key component of the VA provider network, but
agreements will become more standardized, with a focus on continuity and quality of
care. The consolidated Program aims to expand emergency treatment (currently
provided through 38 U.S. Code (U.S.C.) Section 1703, 38 U.S.C. Section 1725, and
38 U.S.C. Section 1728) and remove certain requirements in order to limit the denial of
emergency treatment claims (see Legislative Element 2Patient Eligibility
Requirements). Programs executed through contract (e.g., Patient-Centered
Community Care (PC3), Project ARCH, and Dialysis) may be renewed, modified,
phased out, or replaced in accordance with the provider network strategy for the
New VCP. This addresses the Independent Assessment Report recommendation to
Develop a long-term comprehensive plan for provision of and payment for non-VA
health care services. 14

System of Systems for the New VCP


In addition to streamlining systems for purchasing community care, the New VCP will
form an integrated component of the future system of systems that will support the
delivery of high-quality care and a consistent Veteran experience inside and outside of
VA facilities. The system of systems that will support the New VCP is illustrated in
Figure 4. The VA care delivery process that informs the system structure was
developed by considering the Veteran journey and desired Veteran experience in the
context of the five focus areas of this report (Veterans We Serve (Eligibility), Access to
Community Care (Referral and Authorization), High-Performing Network, Care
Coordination, and Provider Payment (Claims)). The requirements necessary to support
the desired Veteran experience were then grouped into a set of supporting systems and
processes. The VA system of systems that will support the New VCP will enable a
seamless care delivery experience, regardless of where care is provided.

14

Independent Assessment Report Section I. Business Processes

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Plan to Consolidate Community Care Programs

Figure 4: System of Systems Approach for the New VCP


Additional details on the component requirements and processes for these systems are
contained within this report. The system of systems approach will enable Veterans and
community providers to have a clear understanding of how community care is
accessed; how payments are processed; what documentation is required; and where to
go with inquiries, appeals, and grievances. It will also allow for the collection and

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Plan to Consolidate Community Care Programs

analysis of outcome-focused quality of care and performance metrics to support


leadership reporting and process improvement.

Integrated Customer Service Systems


The New VCP will offer standardized customer service systems to address inquiries,
appeals, and grievances from Veterans and community providers. These systems will
be a part of the MyVA customer service infrastructure to enable a seamless Veteran
experience across VA. The customer service systems necessary to support the New
VCP will require properly resourced customer service centers with appropriate training
to handle and resolve inquiries from Veterans and community providers (e.g., eligibility
determinations, covered services). It will also require escalation processes for timely
resolution of issues that cannot be addressed by front-line staff, through a formal appeal
process for authorizations and/or claims payment focused on timely issue resolution. In
addition to traditional telephonic customer service, the program will implement
multichannel options for accessing customer service, including a web-based portal,
email, and self-service. This will allow Veterans and community providers to interact
with VA in the manner and time of their choice.

Integrated Care Coordination Systems


Effective care coordination is critical to enabling a Veteran-centric care experience and
supporting positive health outcomes through clear continuity of care and appropriate
care and disease management. The New VCP defines a clear process for transfer of
medical documentation between VA and community providers when Veterans are
referred into the community (see Legislative Element 9Medical Records
Management). The program also will establish objectives, roles, and processes for care
coordination to enable a smooth Veteran experience across VA and community
providers. The care coordination process for the New VCP will be centered on
Veterans relationships with their PCPs. The PCP and supporting coordinator staff,
whether at a VA facility or in the community, will assist Veterans with basic care
coordination and patient navigation regarding scheduling appointments and seeking
appropriate follow-up care. Veterans receiving care from community PCPs that do not
have the capacity or capability to provide required coordination will be able to rely on VA
for those services. For Veterans requiring more robust care coordination, regardless of
whether they see a VA or community PCP, VA also will provide programs for care and
disease management and case management, as appropriate. This model will integrate
with and utilize established and evolving care coordination models at VA, such as
PACT.

Integrated Administrative Systems (Eligibility, Patient Referral,


Authorizations, and Billing and Reimbursement)
The New VCP will establish a single set of eligibility criteria for Veteran community care
with a focus on providing access to care while allowing Veterans a choice in the

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Plan to Consolidate Community Care Programs

providers they wish to see (see Legislative Element 2Patient Eligibility Requirements).
The New VCP also establishes a single streamlined process for referrals and care
authorizations and will define a select list of services requiring prior authorization (see
Legislative Element 3Authorization Process). The Program will implement a claims
solution to accurately and efficiently adjudicate all claims for community care, based on
a simplified reimbursement rates and value-based payments (see Legislative Element
4Billing and Reimbursement Process, Legislative Element 5Provider
Reimbursement Rate, and Legislative Element 7Prompt Payment Compliance). The
New VCP also will provide more convenient access to pharmacy services and DME
while preserving VAs favorable, volume-driven rates for these services. It will also
include partnering with a retail pharmacy network to support convenient access for
urgent/emergent fill prescriptions. The revised processes will preserve VAs
volume-driven buying power while providing these services in a more intuitive and
convenient way for Veterans and community providers.

High-Performing Network Systems


The New VCP defines a clear strategy for identifying and credentialing community
providers to create a high-performing community network. This network will provide
Veterans with the tools and information necessary to choose a high-quality provider that
is right for their health care needs. The network will have a tiered structure with a core
tier, including established Federally funded partners (DoD, IHS, THP, FQHC) and
academic teaching affiliates. It will also identify Preferred providers based on quality,
value and a compact to serve Veterans. Finally, network management systems will
include quality and value of care metrics that will support consistent evaluation and
refinement of the New VCP network (see Legislative Element 6Plan to Develop
Provider Eligibility Requirements).

Integrated Operations Systems (Enterprise Governance, Analytics, and


Reporting)
The New VCP will be managed by a new DUSH for Community Care who will be
designated to administer VAs community care program. Establishing national
management of and accountability for the program, with the right leadership structures
and resources, will support a consistent experience with the New VCP across facilities.
Similarly, leadership and management structures for community care will be
standardized locally within facilities to support consistent implementation and
management of the program. This addresses the Independent Assessment Report
recommendation that VA should develop a stronger program management structure for
purchased care and allocate responsibility and authority to the most appropriate
levels. 15

15

Independent Assessment Report Section C. Care Authorities

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Plan to Consolidate Community Care Programs

In order to provide VA and Congressional leadership with visibility into the performance
of the New VCP, VA will implement a consistent reporting process across facilities,
using best practices for metrics, data collection, and reporting. Wherever possible,
metrics will be consistent with industry and other Federal agencies to allow VA to
benchmark quality of care and program performance against peer organizations.
Metrics will include outcomes related to Veterans access to care, utilization of care, the
quality and value of care, and Veteran and community provider satisfaction with the
program. Metrics will provide VA with the information necessary to improve care and
health outcomes for individuals (e.g., using claims and medical records data to identify
conditions requiring disease management), which will show the Programs impact on
Veterans. This aspect of the New VCP also responds to the recommendation that VA
should collect better data to accurately estimate the demand for and use of purchased
care from the Independent Assessment Report. 16
Risks and Implementation Considerations: Refer to the Transition Plan (Legislative
Element 10) section of this report.

Impact
Table 1: Impact of the Single Program for Non-Department Care Delivery
Stakeholder

Potential Impact

Veteran

The New VCP creates an efficient, intuitive, and Veteran-centric experience for community
care through streamlined eligibility criteria and administrative and clinical processes. There
will be less confusion for Veterans as to when and how they can access community care.

Community
Provider

The New VCP will simplify and standardize community providers interaction with VA.
Streamlined processes for referrals and authorizations, exchange of medical records and
care coordination, and claims submission and reimbursement consistent with best practices
should increase providers willingness to participate in the VA network.

VA

Consolidating existing community care programs into the New VCP will reduce confusion
among VA providers and staff about when and how to use community care. It should also
greatly improve VAs community care operations, allowing VA to focus on providing excellent
care and service to Veterans.

16

Independent Assessment Report Section C. Care Authorities

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4.2

Element 2: Patient Eligibility Requirements

Legislation
An identification of the eligibility requirements for any such care and services, including
with respect to service-connected [(SC)] disabilities and non-SC disabilities.

Summary
Currently, overlapping eligibility criteria for different
Key Activities
methods of accessing community care creates
Create a single, consistent set of
confusion among Veterans, community providers,
eligibility requirements
and VA staff. Eligibility to enroll in and access VAs
Expand and simplify access to
health care system will not change with the New
emergency treatment and urgent care
VCP. However, the New VCP defines a single set
of eligibility requirements for the circumstances
under which Veterans may choose to receive health benefits from community providers.
This will enable timely and convenient access to care in alignment with best practices.

Background
Current eligibility creates confusion due to multiple, overlapping criteria for each
different method of purchasing care. The New VCP will reduce confusion by
standardizing requirements across facilities regarding when a Veteran may choose to
receive community care, while still providing local flexibility to respond to unique needs
of Veterans (e.g., local services, geography, and undue burden). The need for
simplifying eligibility criteria directly addresses the recommendation to Streamline
programs for providing access to purchased care and use them strategically to
maximize access. outlined in the Independent Assessment Report 17 The eligibility
criteria will be grouped into the following categories:

Hospital Care and Medical Services: Patient eligibility criteria for the New VCP will
provide Veterans with timely and convenient access to care based on wait-times,
distance to a VA PCP, or availability of services.
Emergency Treatment and Urgent Care: Eligibility criteria will increase access to
these services and simplify access rules to prevent the denial of claims for the
appropriate use of these services.
Outpatient medication and DME; extended care services: Eligibility criteria will
not be altered in this report, as any adjustment would constitute a fundamental
change to the VA health benefit.

VA compared the current eligibility criteria for purchasing community care to commercial
health plans and Federal program approaches to develop the New VCP criteria. A
number of findings from this review informed design of the patient eligibility criteria for
the New VCP.
17

Independent Assessment Report Section B: Health Care Capabilities

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Eligibility for VA Health Benefit and Eligibility for Community Care


Eligibility for community care is independent of eligibility to enroll in VA health benefits.
A Veteran must be eligible for and enrolled in the VA health benefit before VA will
evaluate the Veteran for eligibility for community care. Eligibility for enrollment in the VA
health benefit is based on level of SC disability, other special attributes (e.g., winners of
the Medal of Honor and former Prisoners of War), and income. These characteristics
determine a Veterans enrollment priority group. Enrollment priority groups range from
1 to 8, with 1 being the highest priority. All enrolled Veterans enjoy access to VAs
comprehensive medical benefits package; however, some benefits (e.g., dental care)
have additional statutory eligibility requirements. After a Veteran is enrolled in VA
health care, the criteria for VAs various methods for purchasing care in the community
then can be applied to determine when a Veteran may receive his or her health benefits
outside of a VA facility.

Unique Considerations for VA


There are a number of factors that make VA unique compared to commercial health
plans.

18
19

Coverage VA is required to provide coverage to Veterans in areas where VA does


not have physical facilities or an established provider network. Commercial health
plans generally do not offer products where they cannot meet coverage
requirements.
Other Health Insurance (OHI) Approximately 78 percent of Veterans have OHI
and only rely on VA for certain services (e.g., hearing aids and eyeglasses).
Changing the services Veterans are eligible to receive in the community or what they
pay for those services could affect Veterans reliance on VA versus OHI, including
TRICARE, Medicare, and Medicaid.
Teaching and Research Missions In addition to providing high-quality care to
men and women Veterans, VA has research and education missions critical to the
VA system and the nation as a whole. In 2014, VA supported 2,224 medical and
prosthetic research projects totaling $586M in research investment 18 and provided
clinical training to 41,223 medical residents, 22,931 medical students, 311 Advanced
Fellows, and 1,398 dental residents and dental students19. In addition, many
Veterans value participation in VA training and research and consider them to be an
important part of the VA care experience. Over time, decreasing utilization of VA
facilities may jeopardize VAs ability to deliver on these missions.

Source: Veterans Health Administration, Office of Research and Development


Source: Veterans Health Administration, Office of Academic Affiliations

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Current State
VA has multiple sets of eligibility criteria for the various authorities and methods of
purchasing community care. Several of these criteria overlap, creating confusion
among Veterans, community providers, and VA staff and providers. Broadly, these
criteria have focused on providing surge capacity and have been grouped into three
categories:
1. Wait-Times for Care: VA was not able to provide the service within an acceptable
time frame, based on medical need.
2. Geographic Access/Distance: A VA facility was not available within an acceptable
travel distance of the Veterans home.
3. Availability of Service: A facility in the local VA network either did not provide the
required service or there was a compelling reason why the Veteran needed to
receive care from a community provider.
Additionally, eligibility varies by the category of care (hospital care and medical
services; emergency treatment; extended care; outpatient medication; and DME):

Hospital Care and Medical Services


Community care eligibility for Hospital Care and Medical Services, including Dentistry, is
the primary source of Veterans confusion. Table 2 highlights the overlaps caused by
the presence of several methods for purchasing care.
Table 2: Current-State Eligibility CriteriaHospital Care, Medical Services, and
Dentistry
Eligibility
Category

Specific Criteria

Example of Methods Using


the Criteria

Wait-Times for
Care

An appointment cannot be scheduled within the wait-time goals


for VA to provide the service or within the clinically necessary
time frame indicated by the provider if that time frame is less
than the wait-time goals of VA.

Veterans Choice
Program

A facility determines that service cannot be provided within an


acceptable wait-time.

PC3
Individual authorizations
Federally funded
partnerships
Academic teaching
affiliates

Geographic
Access/
Distance

The Veteran lives >40 miles driving distance from the closest
VA facility with a full-time primary care physician
OR
The Veteran faces an excessive burden in accessing a VA
facility, including:

Geographical challenges
Environmental factors
Medical conditions that affect travel

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Veterans Choice
Program

Plan to Consolidate Community Care Programs

Eligibility
Category

Specific Criteria

Availability of
Service

Example of Methods Using


the Criteria

Other factors (nature of care, frequency of care, and need


for an attendant)

A facility determines that service cannot be provided within an


acceptable geographic distance.

PC3
Individual authorizations

Veteran lives more than 60 minutes driving time from nearest


VA health facility (primary care), 120 minutes (acute hospital
care), or 240 minutes (tertiary care).

Project ARCH

A facility determines that service cannot be provided internally


because the facility does not provide the service or has chosen
to buy service from the community.
OR
A facility determine there is a compelling reason why a Veteran
needs to receive care from a community provider.

PC3
Individual authorizations
Federally funded
partnerships
Academic teaching
affiliates
Dialysis Contracts

Emergency Treatment
Currently, a Veteran is eligible to receive emergency treatment through community care
by authority of 38 U.S.C. Section 1703, 38 U.S.C. Section 1725, and 38 U.S.C.
Section 1728. Eligibility for emergency treatment varies by authority. Table 3 outlines
the current-state eligibility criteria for emergency treatment.
Table 3: Current-State Eligibility CriteriaEmergency Treatment
Authority

Specific Criteria

38 U.S.C. Section
1728

It is determined that the care needed met the definition of emergency treatment under 38
U.S.C. Section 1725(f)(1)
AND
The Veteran was receiving care for an SC condition or a non-SC condition is held to be
aggravating an SC condition, or the Veteran is permanently and totally disabled, or in certain
instances when the Veteran is participating in a vocational rehabilitation program under 38
U.S.C. Chapter 31
AND
The claim is filed within two years of the date of service

38 U.S.C. Section
1725

It is determined that the care needed met the definition of emergency treatment under 38
U.S.C. Section 1725(f)(1)
AND
The emergency services were provided in a hospital emergency department or similar facility
held out as a providing emergency care to the public
AND
The Veteran is enrolled for VA health care
AND
The Veteran has received care from VA in the 24 months prior to the receipt of the
emergency care
AND
The Veteran is personally liable for the payment for the care

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Plan to Consolidate Community Care Programs

Authority

Specific Criteria
AND
The Veteran is not eligible for reimbursement under 38 U.S.C. Section 1728
AND
The claim was filed within 90 days of the date of service

38 U.S.C. Section
1703

VA was notified within 72 hours of the episode of care


OR
The Veteran was referred by VA to a community emergency room (ER) from a VA facility or
nursing home

Note: Prudent Layperson Definition of Emergency. When such care or services are
rendered in a medical emergency of such nature that a prudent layperson reasonably
expects that delay in seeking immediate medical attention would be hazardous to life or
health. 20
Since determination of these claims is nuanced, and unclear for Veterans, there are a
large number of denied claims. When denied, the financial responsibility for these
claims, which can be substantial, often falls on Veterans or their OHI, resulting in
unanticipated financial challenges for Veterans. As an example, between the beginning
of FY 2014 and August 2015, approximately:

89,000 claims were denied because they did not meet the timely filing requirement.
140,000 claims were denied because a VA facility was determined to have been
available.
320,000 claims were denied because the Veteran was determined to have OHI that
should have paid for the care.
98,000 claims were denied because the condition was determined not to be an
emergency. 21

In FY 2014, approximately 30 percent of the 2.9M emergency treatment claims filed with
VA were denied, amounting to $2.6B in billed charges that reverted to Veterans and
their OHI. Many of these denials are the result of inconsistent application of the
prudent layperson standard from claim to claim and confusion among Veterans about
when they are eligible to receive emergency treatment through community care.
Additionally, VA is not authorized to reimburse Veterans for urgent care, which is
typically lower cost than emergency treatment, and encourages health care in the
appropriate setting.

Extended Care
VA provides extended care through community providers via a number of different
mechanisms. It is out of the scope of this effort to adjust the eligibility criteria for
20
21

Source: 38 U.S.C. 1725(f)(1)(B)


Source: VHA Chief Business Office, Office of Informatics

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extended care, as any change would constitute a fundamental change to the VA health
benefits package.

Outpatient Medication and DME


In order to take advantage of favorable rates for outpatient medication and DME, VA
currently requires Veterans to receive these services through VA facilities in most
cases. The primary exception to this requirement is urgent prescription fills when a VA
pharmacy is not available. However, VA currently does not have a national contract for
a retail pharmacy network to provide these services. Currently, Veterans must pay for
medications out of pocket and then seek reimbursement from VA.

Future State
The New VCP does not make changes to the VA health benefit or eligibility
requirements for enrollment in VA health care. The Program will give Veterans who are
eligible for community care the choice to access some or all of their health benefits in
the community, when the medically needed care is not conveniently available in a VA
facility.
The objective of the New VCP is to create a set of criteria that are simple and intuitive
for Veterans, community providers, and VA staff. This will be accomplished by
eliminating the multiple overlapping criteria for accessing Hospital Care and Medical
Services, including Dentistry, in the community. The single, nationally defined set of
eligibility criteria for the New VCP can be consistently implemented while providing VA
facilities the flexibility to respond to unique circumstances, such as excessive burden in
traveling to a VA facility or the medically-indicated need to see a provider in a timeline
shorter than the VA wait-time standard for a service. In addition, the New VCP includes
simple criteria for accessing Emergency Treatment and Urgent Care. This should
increase access and reduce denied claims while incentivizing appropriate use of these
services.
Eligibility criteria for each category of care are described below.

Hospital Care and Medical Services


The eligibility criteria for Hospital Care and Medical Services, including Dentistry
services, in the community will continue to be focused broadly on wait-times for care,
geographic access/distance, and availability of services. The criteria will be streamlined
into a single set of rules applied across the VA health care system. To ensure VA
meets the unique needs of Veterans, VA will have flexibility at the local level through
clarified guidance on exceptions. The process also will include clear appeal and
grievance mechanisms for Veterans to dispute eligibility determinations.

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When Veterans are determined to be eligible for community care, VA will provide them
with information on providers and appointment availability at VA and in the community.
This will allow Veterans to choose a convenient appointment from the provider of their
choice. The proposed eligibility criteria for Hospital Care and Medical Services are
outlined in Table 4.
Table 4: Future-State Eligibility CriteriaHospital Care and Medical Services
Eligibility
Criteria

Proposed Criteria
Veterans Choice Program Future State

Wait-Times for
Care

An appointment cannot be scheduled within VA wait-time goals for providing the service or
within the clinically necessary time frame indicated by the provider if that time frame is less
than VA wait-time goals

Geographic
Access/Distance

The Veteran lives 40 miles or farther driving distance from a PCP as designated by VA
OR
The Veteran faces excessive burden in accessing care at a VA facility, including:

Geographical challenges

Environmental factors

Medical conditions that affect travel

Other factors (nature of care, frequency of care, and need for an attendant)

Availability of
Service

A facility does not provide the service or has chosen to buy service from the community
OR
There is a compelling reason why the Veteran needs to receive the service outside a VA
facility (e.g., female victims of MST unable to be seen by a female provider)

The primary change in this proposal is to focus eligibility for geographic access/distance
on access to a PCP. PCPs play a critical role in coordinating care and providing
preventative care, so convenient access is necessary. Veterans eligible for the New
VCP under either of the geographic access/distance criteria will have the option to
choose a community PCP. The community PCP could then refer the Veteran to
specialty care in the community or at VA as appropriate and authorized by VA. This
approach is consistent with best practices, which emphasize providing access to a PCP.

Emergency Treatment and Urgent Care


Under the New VCP, VA plans to extend access to emergency treatment and urgent
care in the community to all eligible Veterans. VA plans to provide Veterans access to
urgent care centers. Industry best practice minimizes the denial of emergency
treatment claims to avoid discouraging patients from seeking necessary emergency
treatment. The New VCP criteria are consistent with this approach, and will focus on a
more consistent application of the prudent layperson definition of emergency treatment
across claims. More consistently applying this definition will also reduce the
administrative burden on VA to conduct a nuanced review of each emergency treatment
claim. Detailed overviews of Emergency Treatment and Urgent Care eligibility criteria
are outlined in Table 5.

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Table 5: Future-State Eligibility CriteriaEmergency Treatment and Urgent Care


Eligibility
Criteria

Proposed Criteria
Veterans Choice Program (Future State)

Emergency
Treatment

1.
2.
3.
4.

The Veteran is enrolled in VA health benefits.


The Veteran has received care through VA within the last 24 months.
Symptoms satisfy the prudent layperson definition of emergency.
There is no authorization requirement (preservice or post-service) for emergency treatment.

Urgent Care

1. The Veteran is enrolled in the VA.


2. The Veteran has received care through VA within the last 24 months.
3. Accesses care at a VA designated urgent care center.

While VA seeks to provide eligible Veterans with increased access to emergency


treatment and urgent care in the community, it is important to encourage Veterans to
use these services appropriately and not as a substitute for primary care. Consistent
with industry best practices, the New VCP will require cost-sharing for emergency
treatment and urgent care. This is an important tool to encourage Veterans to utilize
their PCPs for most care and seek emergency treatment or urgent care only when
necessary. Cost-shares will be waived if the Veteran is admitted from the emergency
room or urgent care center or if it represents an undue financial burden to the Veteran.

Extended Care
No changes are being made to how VA provides extended care in the community. The
majority of these services are provided in the community today and changing the
eligibility criteria would constitute a fundamental change to the VA health benefit.

Outpatient Medication and DME


No changes are being made to VAs approach to provide routine outpatient medication
and DME due to the favorable rates available to VA. VAs evidence-based formulary
management system enhances medication safety and cost-effectiveness. However, in
the implementation phase, VA will work to establish new processes for coordinating
orders between VA facilities and community providers to support convenient access to
these services. In the case of non-VA prescribed medications, VA has an approved and
funded IT project (Inbound Electronic Prescribing) to streamline this process.
Additionally, VA plans to develop requirements for a national retail pharmacy network
contract needed to meet its current needs for urgent prescription fills in the community.
Risks and Implementation Considerations: Refer to the Transition Plan (Legislative
Element 10) section of this report.

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Impact
Table 6: Impact of the Patient Eligibility Requirements
Stakeholder

Potential Impact

Veteran

The New VCP eligibility criteria will reduce confusion among Veterans about when they
are eligible to receive community care and for what services they are eligible. It also
will expand access to community care for emergency treatment and urgent care
services and limit cases where Veterans are held responsible for a bill for emergency
treatment or urgent care because they did not fully understand the criteria for VA
coverage. In addition, the New VCP will provide Veterans with increased choice in
providers they can see in the community.

Community Provider

Community providers will have a clearer understanding of what services the Veterans
they see are eligible to receive under the New VCP.

VA

The New VCP eligibility criteria will provide VA providers and staff with clear,
consistent guidance on when Veterans should be referred to the community. They
also will reduce confusion about which method to select for purchasing care for a
particular Veteran or service and reduce the administrative burden on VA of
individually reviewing all emergency treatment claims.

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Plan to Consolidate Community Care Programs

4.3

Element 3: Authorizations

Legislation
A description of the authorization process for such care or medical services, including
with respect to identifying the roles of clinicians, schedulers, any third-party
administrators (TPAs), the VAs Chief Business Office, and any other entity involved in
the authorization process.

Summary
Currently, VAs process for referrals and
Key Activities
authorizations to coordinate care, manage clinical
Redesign clinical authorization process
utilization, and improve health outcomes is largely
Create centralized authorization
manual. This causes delays in care and
function
Reduce number of services requiring
inconsistency in reviews. Best practices call for
authorization
automation and process improvement for
Create and collect metrics to monitor
authorization reviews. VA will use a system of
effectiveness of new authorization
systems approach to establish and refine business
process
rules, create a central authorization center, train
staff, and implement technologies to support referrals and authorizations. VA will
standardize the approach to referrals and authorizations. The business rules and
process will be consistent for internal and community provided services. VA intends to
benchmark and monitor performance, addressing the Independent Assessment
recommendation to align performance measures to those used by industry, giving VA
leadership meaningful comparisons of performance to the private sector. 22

Background
Referrals and authorizations are mechanisms to coordinate and manage community
care while managing medical need and cost, as defined in Table 7
Table 7: Referral and Authorization Definitions
Definition

Key Word
Referral
Authorization

A written or electronic transfer of care initiated by a clinician that enables a patient


to see another provider for specific care or to receive medical services.
A decision that a health care service, treatment plan, prescription drug, or DME is
medically necessary.

PCPs play a pivotal role in coordinating care. Referrals enable a Veteran to receive
services through another provider. However, certain services, such as purely cosmetic
procedures not related to remediation of an underlying health condition, high-cost
services, or experimental services, require additional clinical review to confirm necessity
22

Independent Assessment Report Section I. Business Processes

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and consistency with best practices. Referral and authorization processes should be
standardized inside and outside VA, and facilitated through automation to enable more
proactive Veteran care management. To support effective implementation, the provider
network should be routinely educated. To manage disputes, a formal appeals process
will be implemented.

Current State
Currently, the referral and authorization process varies by program and whether a
Veteran is accessing care due to wait-times or geographic access/distance criteria. All
non-emergent services require a referral and administrative documentation. This
process is repetitive, time consuming, and lacks clear ownership. Furthermore, a new
referral or authorization may need to be generated for services covered within the same
episode of care. The current process is variable across VA sites and is carried out by a
variety of individuals with multiple roles and varying skill levels. There are no clear
performance metrics to evaluate the efficiency of the process. Consequently, there is
no clear ownership of the process, making it challenging to track and improve.

Future State
The New VCP will improve the referral process through automation and removal of
redundant reviews. A subset of services will require an authorization for the care to be
provided based on medical necessity to improve visibility into utilization of these
services. For consistency, authorizations will be managed centrally and supported with
industry accepted standards and clinical guidelines. This will facilitate the development
of performance metrics to continuously evaluate and improve the authorization process,
and support improvement in utilization of services for best value for the Veteran.
A call center will be available for questions from Veterans, caregivers, and community
providers. A formal, timely appeals process will provide Veterans a clear point of
contact for concerns about the status of their authorization.

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Risks and Implementation Considerations: For additional information, refer to the


Transition Plan (Legislative Element 10).

Impact
Table 8: Impact of Authorizations
Stakeholder

Potential Impact

Veteran

Veterans will have timely access to care and a clear understanding of when and where
they are eligible for care. When authorization questions arise, there is a clear path for
appeals through the call center. Veterans will receive care that is effective and
consistent with clinical guidelines and industry practices.

Community Provider

Community providers will benefit from authorization requirements consistent with industry
standards and experience a decrease in administrative burden. This will provide more of
an incentive to participate in the high-performing network.

VA

VA will benefit from a decreased administrative burden and have a standard process with
defined accountability, consistent outcomes, and reduced turnaround times. Central
authorization control will enhance VAs visibility into Veterans needs. The central
authorization process will improve staff competency and efficiency.

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4.4

Element 4: Billing and Reimbursement

Legislation
The structuring of the billing and reimbursement process, including the use of thirdparty medical claims adjudicators or technology that supports automatic adjudication.

Summary
Key Activities
The current billing and reimbursement system
Introduce automation, including auto
is a decentralized and highly manual process.
adjudication, to billing and
A successful billing and reimbursement system
reimbursement processes
auto adjudicates a high percentage of claims to
Create and collect metrics to monitor
pay providers promptly and correctly. To
effectiveness of billing and
reimbursement processes
achieve this, best practices dictate using
centralized services and technology, combined
with standardized processes and business rules. This addresses the Independent
Assessment Report recommendation to employ industry standard automated solutions
to bill claims for VA medical care (revenue) and pay claims for Non-VA Care (payment)
to increase collections, to improve payment timeliness and accuracy. 23 To achieve
these improvements, VA will implement new business processes and conduct analyses
to determine potential claims solutions.

Background
Efficient adjudication is the key to effective billing and reimbursement processes.
High-performing networks invest in centralized, scalable auto adjudication technology
platforms and use simplified product and reimbursement rules to facilitate high levels of
auto adjudication. This enables automation of most claims and only requires review of
claims in question, reducing delays in payment. While this type of technology
investment will have significant up-front costs, efficiency gains, savings, and additional
key analytic capabilities will be generated once the solution is complete.
Auto adjudication of claims is made possible by establishing standard rules and
processes, and integrating with complete patient and provider data. Systems
interoperability allow for flexibility, enabling organizations to quickly respond to
regulatory and best practice changes. Modern claims platforms can model care
outcomes, and identify fraud, waste, and abuse through data analytics. Industry
standards do not require the receipt of medical records for payment. VA does have this
requirement, which often causes delays in payment. As VA improves claims
processing, VA will no longer require medical records for reimbursement. VA will strive
to improve the automation of systems to process medical records and conduct

23

Independent Assessment Report Section I. Business Processes

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retrospective audits to confirm their receipt and develop lessons learned to support
continuous improvement.

Current State
The current VA claims infrastructure and claims process are complex and inefficient due
to highly manual procedures, and VA lacks a centralized data repository to support auto
adjudication.
There are more than 70 centers processing claims across 30 different claims systems,
resulting in inconsistent processes. Limited automation and manual matching of claims
to authorizations prevents efficient adjudication. Low electronic data interchange (EDI)
claims submission rates, decentralized and inconsistent intake processes, and limited
staff productivity standards (i.e., workload metrics) result in labor-intensive, paper-based
processes that generate late, and sometimes incorrect payments.

Future State
VA will pursue a claims solution and simplified processes as it evolves to achieve parity
with best practices. VA will focus on:

Standardizing business rules and logic to support claims processing.


Improving reimbursement processes by removing the requirement for medical
records returns with claims submission for payment.
Implementing productivity standards to better manage supply and demand (claims
adjudicators).
Improving interfaces and coordination with dependent systems (e.g., Eligibility).
Implementing reimbursement models to recognize and promote Connected Health
activities, such as outreach to Veterans for self-help, health promotion and
secondary prevention, telehealth, team-based care, and Veteran education.

In the long term, VA will use a scalable, flexible claims platform that supports emerging
value-based care models, and streamlines data maintenance, storage, and retrieval.
This new claims solution will support VAs efforts to reduce waste, fraud, and abuse. In
addition, the VA claims solution will integrate with Veteran Eligibility Systems,
Authorization Systems, and standardized fee schedules to support auto adjudication.
Integration with fee schedules will support new payment models and enable better
tracking and billing integration with OHI (See Legislative Element 5Provider
Reimbursement Rate). VA will also integrate the claims processing system with patient
information, increasing VAs ability to efficiently bill OHI. As VA becomes more efficient
with processing claims, it will consider consolidating claims processing for other
programs (e.g., CHAMPVA). Taken together, the new claims solution will allow VA to
pay on time and correctly while meeting PPA compliance (see Legislative Element 7Prompt Payment Compliance). VA will coordinate referral management with tracking
financial obligations to provide the basis for resource and process adjustments based
on forecasted versus actual use of funds.

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VA will determine whether to improve the system through the adoption of a new system
or by purchasing the required capabilities externally. VA will oversee adherence to
business rules, standardize internal controls, and have proper access to systems
holding information to be reviewed. Keeping in line with best practices, VA will conduct
claims audits for accuracy. VA also will provide compliance oversight for the New VCP
Prompt Payment compliance process owner in accordance with VA Directives,
Handbooks, and other applicable policies. To monitor and improve performance of
billing and reimbursement, VA will use industry standards as metrics for continuous
process improvement.
Risk and Implementation Considerations: For additional information, refer to the
Transition Plan (Element 10) section of this report.

Impact
Table 9: Impact of Billing and Reimbursement
Stakeholder
Veteran

Potential Impact
Implementing new claims systems will reduce the risk of billing Veterans when provider
reimbursement is either delayed or denied.
Communications improvements in customer care will directly improve the Veteran
experience. Systems integration and auto adjudication will improve the efficiency and
accuracy of claims from community providers, and thereby introduce more clarity around
timing of billing and reduce the risk of Veterans referred to collections notices by
community providers.
Timely re-imbursement of community providers will motivate such providers to participate
in the VA provider network, thereby improving access for Veterans.

Community Provider

Improved processes, rules, and systems will improve claims processing accuracy and
predictability, enable VA to comply with the PPA, and therefore provide an incentive for
providers to join and remain in the network.

VA

By improving VAs billing and reimbursement policies and processes, VA will improve
timeliness, accuracy, and efficiency of claims processes, reducing costs associated with
late penalties, and strengthen business analytics and utilization review capabilities of the
Department.

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Plan to Consolidate Community Care Programs

4.5

Element 5: Provider Reimbursement Rate

Legislation
A description of the reimbursement rate to be paid to health care providers under such
program.

Summary
Key Activities
Currently, VA establishes provider rates through
Consolidate fee schedules and tie to
local negotiations using a complex, inconsistent
Medicare
process. This results in a lack of transparency for
Increase transparency of
community providers and VA staff regarding
reimbursement rates to providers
reimbursement rates. High-performing networks
Allow regional variation, as needed
provide transparency to providers through
standardized, negotiated reimbursement rates. VA will standardize reimbursement
rates to align with regional Medicare rates under a single program and will remain the
primary payer. For services not covered by Medicare, VA will use other fee schedules
or conduct negotiations around usual and customary (U&C) rates. U&C rates are rates
paid for a medical service in a geographic area based on the amount providers in the
area usually charge for the same or similar medical service. This is consistent with the
Independent Assessment Report recommendation VA and Congress should adopt a
consistent strategy for setting reimbursement rates across purchased care initiatives. 24
VA will continue to use established payment mechanisms with DoD, IHS, THP, FQHC,
and academic teaching affiliates while at the same time moving toward paying Medicare
rates for commercial partners. The change will allow VA staff to more easily match
rates and reduce variance in the rates being paid to community providers. As the health
care industry evolves, VA will participate in models of value-based care to provide the
highest quality care for Veterans.

Background
The purpose of a fee schedule is to communicate the rate a provider will be paid for the
services they render. The design of the fee schedule may incentivize providers to
participate in the network and can be used to reward delivery of high-quality care.
CMS is the largest primary payer in the U.S. and employs a Medicare rate-setting
committee that influences market reimbursement rates. The CMS fee schedule
includes geographic variations for care along with Graduate Medical Education, among
other factors. For services not specified in the fee schedule, organizations will pay U&C
or negotiated rates.
To create incentives for better health outcomes, best practices are shifting from a feefor-service model to value-based care arrangements. In this model, organizations
24

Independent Assessment Section C. Care Authorities

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Plan to Consolidate Community Care Programs

reward based on achievement of quality processes and clinical outcomes (e.g.,


measuring blood pressure and cholesterol or achieving control of blood pressure and
cholesterol). Providers may be penalized for poor outcomes, medical errors, or
increased costs. CMS is currently piloting various models of value-based care, which
VA can work to replicate, as appropriate.

Current State
Through legislation and VA-implemented programs, a number of community care
programs overlap in the services they provide and have multiple fee schedules. The
schedules are set both locally and nationally, which increases variation and complexity
across programs and medical centers. Finally, in some instances, VA pays billed
charges for services without a corresponding rate in a schedule in lieu of negotiating a
more favorable rate.
The current state is confusing for VA staff and community providers. Staff performing
this function are challenged to accurately identify the appropriate reimbursement rate,
causing lengthy processing times and overpayment. Community providers are unsure
about what rate they will be paid when seeing Veterans

Future State
VA will standardize, to the extent practicable, to Medicare rates for the external network.
VA proposes a single rate schedule for the New VCP to provide a clear basis for claims
payment, which will promote timely payments and prevent overpayments through
negotiated rates when a Medicare rate does not exist. This will end the existing
structure of providers having multiple schedules per service. Dentistry 25 will be
reimbursed differently as the Office of Dentistry will continue to use the market to
determine and apply regional market rates for their services. VA will continue using
existing agreements with partners in the VA Core Network; pending legislation will allow
VA to direct care to these authorities (see Legislative Element 6 Provider Eligibility).
VA also plans to evolve toward a value-based care model as the concept matures. As a
facet of value-based care, Preferred providers will be incentivized with higher
reimbursement rates when they meet or exceed performance metrics. Providers may
receive higher reimbursements based on their performance against quality metrics. In
contrast, providers who consistently perform below expected levels may be dropped
from the network. Further, VA will employ an audit function to verify quality in the valuebased model.
Due to their geographic and/or market cost distinctions, VA will customize fee schedules
for certain areas (e.g., Alaska, Hawaii, Guam, Puerto Rico, American Samoa, and the
Commonwealth of the Northern Marianna Islands) or certain services (e.g., scarce
25

Dental Payment Methodology (From NVCC Future State)

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Plan to Consolidate Community Care Programs

specialties and dental care) to maintain a sufficiently robust provider network in these
regions.
Risks and Implementation Considerations: For additional information, refer to the
Transition Plan (Legislative Element 10).

Impact
Table 10: Impact of Provider Reimbursement Rate
Stakeholder

Potential Impact

Veteran

Veterans will benefit from increased provider participation and choice in options since
providers are reimbursed at predictable industry rates. Veterans also will have access to
high-performing providers. This will lead to greater access to providers in the community.

Community Provider

Community providers will benefit from consistent reimbursement rates. Standardized fee
schedules will decrease provider confusion and reduce payment errors. Since rates will
be based on a common schedule with which they are already familiar, there will be little
surprise for providers who see increases or decreases in their rates per service.
As value-based reimbursement is implemented, providers will be rewarded for providing
higher-quality care.

VA

For VA, consistent reimbursement rates will allow for better cost prediction.
Reimbursement rates under the New VCP will reduce payment errors due to elimination
of manual selection of various fee schedules by examiners. Consistent payment rates
will enable better data analytics to support fraud detection

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Plan to Consolidate Community Care Programs

4.6

Element 6: Plan to Develop Provider Eligibility Requirements

Legislation
An identification of how the Secretary will determine the eligibility requirements of
health care providers at non-Department facilities to participate in such program,
including how the Secretary plans to structure a non-Department care network to allow
the maximum amount of flexibility in providing care and services under the program.

Summary
Key Activities

VA currently has a variety of agreements with


Create tiered high-performing provider
providers in the community, but limited national
network
visibility into supply and demand needs. There
Create simplified provider agreements
are no standardized approaches for provider
Standardize credentialing and quality
monitoring
credentialing, quality monitoring, or identification
of best-in-class providers. High-performing
networks in health care apply standardized credentialing and quality criteria. They can
identify and recruit high-quality providers for the network. To move toward this best
practice, VA plans to provide Veterans access to a tiered, high-performing network
(Core and External). The network will reward providers for delivering high-quality care,
while promoting Veteran choice and access. 26,27,28 The VA Core Network includes highquality health care assets in the DoD, IHS, THPs, FQHCs, and academic teaching
affiliates (see Figure 5). The External Network includes commercial providers in
Standard and Preferred tiers based on quality and value performance. Standardized
credentialing will decrease administrative barriers for providers, while more rigorous and
consistent quality monitoring will promote high-quality care for Veterans. 29,30

Background
To identify provider eligibility requirements and design the high-performing network for
VA, this element examines best practices for provider networks, credentialing, and
quality standards.

26

Independent Assessment Report (DemographicsSection 1), Prepare for a changing Veteran


landscape
27 Independent Assessment Report (DemographicsSections 2), Anticipate potential shifts in the
geographic distribution of Veterans, and align VA facilities and services to meet these needs
28 Independent Assessment Report (Health Care CapabilitiesSections 5), Take significant steps to
improve access to VA care
29 Independent Assessment Report (Care AuthoritiesSection 7), VA purchased care contracts should
include requirements for data sharing, quality monitoring, and care coordination
30 Independent Assessment Report (Health Care CapabilitiesSection 8), Systematically study
opportunities to improve access to high-quality care through use of purchased care

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Plan to Consolidate Community Care Programs

Provider network design and implementation are constantly shifting to accommodate


changes to the U.S. health care landscape, including coverage requirements and
provider incentive models. A provider network consists of licensed health care
professionals (e.g., doctors, nurse practitioners, physician assistants, and nurses) and
medical facilities (e.g., hospitals, outpatient surgery centers, and diagnostic imaging
centers) that agree to provide services at pre-negotiated rates. A robust provider
network has an adequate number of providers in terms of quality, mix/type of specialty,
and geographic distribution to meet supply and demand needs.
High-performing tiered networks promote high-quality care, improved health outcomes,
and reduced system costs. 31,32 They include providers who meet the minimum
standards and Preferred providers who meet additional quality and value standards.
These networks help patients identify providers who can deliver culturally competent
care and publish provider information for patients (e.g., quality designations and patient
feedback). High-performing tiered networks balance access to care in areas with few
providers and choice of providers.
To effectively develop and maintain high-performing tiered networks, industry-leading
organizations use network development, contracting and reimbursement, provider
relations, credentialing, and clinical quality monitoring functions. The network
development function implements provider payment strategies and determines the
optimal size, composition, and geographic distribution of the network. Contracting and
reimbursement capabilities include negotiating provider agreements, obtaining
exception approvals, and maintaining reimbursement data. The provider relations
function manages ongoing communication and education initiatives with the provider
community, while also addressing inquiries and grievances. To improve the stakeholder
experience and simplify processes, leading organizations invest in customer service
personnel and web-based tools for patients and providers (e.g., navigation tools to help
patients become familiar with care processes).
Credentialing is the process of reviewing the general qualifications and practice history
of providers using guidance from organizations such as the National Committee for
Quality Assurance (NCQA) or The Joint Commission. Commercial provider networks
review education, training, employment, and disciplinary history. Leading organizations
use credentialing systems that automate tasks and incorporate analytics-driven
decision-making. The processing time for credentialing a new provider is typically 30
business days. Commercial networks re-credential providers to monitor ongoing
adherence to standards based on regular intervals (usually 2436 months). Providers
that do not meet specific standards (e.g., recurring malpractice claims or sanctions
against a professional license) can be removed from the network.
31

R. Steinbrook, The Cost of AdmissionTiered Copayments for Hospital Use, New England Journal
of Medicine; 2004
32 J. Burns, Narrow Networks Found to Yield Substantial Savings, Managed Care; 2012

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Plan to Consolidate Community Care Programs

In the U.S., health care is not delivered consistently. There are notable differences in
health care spending, resource utilization, and quality of care depending on factors such
as the licensed health care professional, medical facility, geographic region, and patient
population. Increased utilization and spending do not always lead to better outcomes. 33
To promote consistent high-quality care that is safe, timely, effective, efficient, and
patient centered, industry-leading organizations are working to measure provider
performance and recognize high performers. Metrics employ evidence-based
performance criteria based on rigorous and transparent methodologies. Sources for
quality measures can include NCQA, the National Quality Forum, AHRQ, and The Joint
Commission. Effective coordination of care and health information management also
directly affect quality of care (see Introduction: Care Coordination and Legislative
Element 9Medical Records Management).

Current State
Current VA community provider relationships are formed through multiple overlapping
programs with Federally funded health care assets and commercial providers. VA
contracts or has agreements with approximately 40 DoD facilities (with access to
TRICARE Managed Care Contractors on a case-by-case basis), 100 IHS facilities, 80
THPs, 700 academic teaching affiliates, 700 FQHCs, 76,000 locally contracted
providers, and 200,000 additional providers through current national contracts. Despite
the large numbers of providers, VA does not have ongoing visibility into many provider
locations, nor an understanding of supply and demand imbalances. Therefore, VA does
not have coverage in certain areas to provide accessible care to Veterans, nor a single
mechanism to actively manage provider relationships.
VA has multiple processes for credentialing community providers and different
credentialing criteria, depending on the authority that is the basis for furnishing
community care.
VA does not have a standardized approach to measure delivery of quality care in
contracts and agreements with community providers. Some sharing agreements are
administered locally, and quality reporting requirements vary depending on the
agreement. As a result, VA currently has limited visibility into best-in-class providers.
Once providers have joined the network, VA does not have a national mechanism to
track quality of care issues. With variable quality monitoring processes, providers are
held to different standards and VA faces a larger burden in monitoring quality
compliance.

33

Executive SummaryDartmouth Atlas of Health Care.


http://www.dartmouthatlas.org/pages/executive_summary.

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Plan to Consolidate Community Care Programs

Future State
To align with VAs mission to better serve Veterans, VA plans to provide access to a
high-performing network drawing from best practices across industry and Federally
funded organizations (See Table 11).
Table 11: Key Elements of the High-Performing Network
High-Performing Network

Applies industry-leading health plan practices for tiered network design


Enhances unique relationships with Federally funded and academic teaching affiliates
Promotes Veteran choice, access to care, and high-quality care delivery
Uses streamlined and consistent credentialing and quality monitoring processes
Incorporates network management functions, including network development, contracting and
reimbursement, credentialing, clinical quality monitoring, and provider relations
Consistently monitors supply and demand changes to make appropriate network adjustments, achieving
access standards and coverage for primary and specialty care
Effectively coordinates care in a Veteran-centered way
Uses clinical and administrative metrics to continually measure and improve performance

VAs high-performing network will be divided into the VA Core Network and the External
Network (Figure 5). The External Network is subdivided into Standard and Preferred
tiers. VA will work toward standardizing requirements with providers in the highperforming network.

Figure 5: High-Performing Network Model

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Plan to Consolidate Community Care Programs

The VA Core Network will include providers in the DoD, 34 IHS, THPs, 35 FQHCs, and
academic teaching affiliates. 36 VAs relationships with these providers are unique and
have evolved over time. Sustaining and expanding Core Network relationships align
with VAs mission, vision, and strategies (see Legislative Element 8: Plans to Use
Current Non-Department Provider Networks and Infrastructure). Because Core
Network providers will be considered a direct extension of VA care, VA will primarily
refer patients to the Core Network before the External Network. 37 VA will work to
develop simple and consistent agreements with Core providers that are principle-based
and focus quality and outcomes.
External providers can belong to Standard or Preferred tiers, which will expand over
time. VA plans to make the process for joining the External Network simple. Providers
in the Standard and Preferred tier must meet uniform credentialing requirements to
participate in the high-performing network. Providers in the Preferred tier must meet
minimum credentialing requirements while also demonstrating high-value care.
The high-performing network will require network development, contracting and
reimbursement, credentialing, clinical quality monitoring, and provider relations
functions. VA will employ an audit function to oversee credentialing and adherence to
quality standards.
Veterans will have the ability to choose community providers and make informed
decisions based on public information. Veterans currently accessing community care
can remain with their community providers, if the provider meets minimum
requirements, or choose other providers in the network. Veterans also can recommend
their providers for addition to the network. VA will consider publishing provider
designations, credentials, and Veteran feedback. To promote awareness about military
culture and unique issues Veterans face, VA will encourage providers to complete
relevant trainings and make available educational resources.
VA faces significant access challenges in delivering care to Veterans due to geographic
limitations and the unique needs of the Veteran population. VA plans to include the

34

The inclusion of Managed Care Contractors through TRICARE will be evaluated separately during
implementation phases.
35 Refers to all Tribal Health Programs that meet CMS certification and CMS conditions of participation, or
have accreditation through the Accreditation Association for Ambulatory Health Care or The Joint
Commission, with which VA has entered a Direct Care Services Reimbursement Agreement.
36 Academic teaching affiliates refers to academic departments or program that have active teaching
relationships with VA and can be part of the VA Core Network. Other academic institutions or
departments without teaching relationships can be part of the External Network. VA plans to retain or
expand relationships under VA Directive 1663.
37 In general, VA plans to refer patients to Core Network providers first, with exception. For example, VA
does not generally refer patients to IHS and THP providers under Direct Care Services Reimbursement
Agreements, and does not plan on changing this arrangement.

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Plan to Consolidate Community Care Programs

highest quality providers, but also recognizes the need to establish a broad and flexible
network providing convenient care near to where Veterans live.
In the high-performing network, credentialing processes will be simple, consistent, and
in alignment with best practices (see Table 12). The re-credentialing process will
evaluate ongoing provider qualifications to confirm health outcomes and adherence to
standards. These can include value, complaint history, Veteran experience, and a
baseline assessment of care appropriateness every 24-36 months. VA will audit and
enforce credentialing practices in the high-performing network.
Table 12: High-Level Provider Credentialing Standards
Provider Credentialing Standards

Educational credentials, certifications, licensure, training, and experience


Employment and pre-employment history
Supplemental attestation questions, disciplinary screening, and sanctions
Agreements with providers to meet access and quality of care standards

VA will work directly with providers currently caring for Veterans to include them in the
network for continuity of care. Providers who meet credentialing criteria will complete a
simple enrollment process and can join the VA network. Over time, poor performing
providers will be removed from the network.
In the VA Core Network, VA will delegate credentialing or perform credentialing
functions when applicable. Federally funded credentialing institutions can include DoD,
IHS, and the HRSA for FQHCs. VA will evaluate current credentialing practices to
determine whether there are difficulties and identify ownership of the process. In the
External Network, either VA or a network manager will assume ownership of
credentialing and will apply industry-leading practices.
VA will work toward establishing simple, consistent, and high-quality agreements with
Core and External Providers in the high-performing network. In order to promote quality
of care, VA will monitor and enforce rigorous quality reporting and performance
standards in line with industry, conduct data analytics on disease management, and
share VA critical pathway information. VA plans to shift toward adopting value-based
care models in the high-performing network (see Legislative Element 5- Provider
Reimbursement Rate).
Creating a prioritized Core Network will maximize the use of high-quality Federally
funded health care assets, while sustaining unique and important VA relationships. In
the External Network, VA promotes high-quality care by creating Preferred and
Standard tiers. For the Preferred designation, providers must meet quality and value
metrics that are based on evidence-based care guidelines. VA plans to uniformly apply

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Plan to Consolidate Community Care Programs

best practices to determine criteria for both tiers. VA will work to determine specific
metric reporting and performance benchmarks using recognized institutions.
Risks and Implementation Considerations: Refer to the Transition Plan (Legislative
Element 10) section of this report.

Impact
Table 13: Impact of Provider Eligibility
Stakeholder

Potential Impact

Veterans

Veterans will have increased access to high-quality care through an expanded network
that promotes quality. Veterans can remain with their existing community providers, if
providers meet minimum requirements, or choose other providers who are best in
class to support their health care needs.

Community Providers

Providers in all tiers will benefit from simpler, consolidated, and integrated claims
processing, medical records management, and provider support services through VA.
Providers in the VA Core Network and Preferred tier may see an increase in patient
referral volume in addition to benefits realized in the Standard tier.

VA

VA will have increased visibility into supply and demand in the network, centrally
monitor provider credentialing and quality, and promote high-value care.

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Plan to Consolidate Community Care Programs

4.7

Element 7: Prompt Payment Compliance

Legislation
An explanation of the processes to be used to ensure that the Secretary will fully
comply with all requirements of Chapter 39 of the Title 31, United States Code
(commonly referred to as the PPA), in paying for such care and services furnished at
non-Department facilities.

Summary

Key Activities

Currently, VA has challenges with consistently


Comply with Prompt Payment for all
purchased care
meeting PPA requirements due to lack of an

Reduce claims backlog


automated claims processing system. In the
future, VA will consistently adhere to PPA, and
follow industry best practices to measure results of the claims adjudication process. To
achieve this, VA will conduct an analysis to determine the best strategies and solutions
to increase its ability to provide timely payment thereby avoiding late penalties.

Background
In 1982, Congress enacted PPA, which requires Federal agencies to pay vendors on a
timely basis and pay interest on late payments. While PPA regulation requires payment
to be made within 30 days after an invoice is received, it does not specifically reference
health-related claims nor define clean claims. A clean claim is one that has all
information required for processing in a timely manner; it has no defect, impropriety, or
special circumstance. An unclean claim is one that is missing information. State
governments have enacted different Prompt Payment legislation that requires health
plans to adhere to certain time frames for claims processing. As a reference, the
average state standard is 30 days for clean claims (ranging from 14-45 business
days).22 This requirement will be clarified in the legislative proposal recommendations.

Current State
Currently, VA does not consistently meet PPA standards. In some programs, such as
CHAMPVA, a 30-day claim processing rate of 95 percent is achieved. However, as of
September 30, 2014, VA paid 76.7 percent of claims within 30 days. A root cause of
low PPA compliance is that claims payment is a manual process, creating a significant
backlog (See Legislative Element 4Billing and Reimbursement). To address the
backlog, VA developed and is executing a phased action plan in terms of people,
process, and technology.

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Plan to Consolidate Community Care Programs

Future State
In the short-term, VA plans to reduce the current backlog by increasing the number of
claims staff. It aims to adhere to best practice guidelines used by several states (e.g.,
paying within 30 days for clean claims). 38 In the long term, VA will use industry best
practices to reach a 95 percent payment rate for clean claims within 30 days. To
achieve this, VA will consider alternate solutions, such as outsourcing billing and
reimbursement, or deploying new technology solutions or updates.
VA will have a mechanism for the reporting and monitoring of claims processing to
manage inventory to PPA standards. VA will establish internal controls that would allow
regular review and updates to the process to obtain additional information about how to
process claims promptly. VA will also review, update, and retrain staff on policies and
procedures to comply with PPA. This will include training both internal staff and TPAs
on new claims adjudication procedures. VA will establish an audit function to monitor
claims processing accuracy. Efforts to develop a consolidated program and automated
claims processing system will allow VA to consistently meet PPA.
Risk and Implementation Considerations: For additional information, refer to the
Transition Plan (Legislative Element 10) section of this report.

Impact
Table 14: Impact of Prompt Payment Compliance
Stakeholder

Potential Impact

Veterans

By improving timeliness of payments, providers will be more likely to participate


within VAs networks. Therefore, Veterans will experience more choices in
community providers.

Community Providers

Network providers will be paid promptly according to industry standards, providing


an incentive to join the network.

VA

As previously discussed in Element 4, new improvements to billing and


reimbursement will improve operations and enable VA to improve compliance to
PPA standards for claims received under a contract or an individual provider.

38

Independent Assessment Recommendations Overview: Highlighting Connections to the Future VCP


Model Recommendations, Slide 15 (Sept 3, 2015).

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4.8
Element 8: Plans to Use Current Non-Department Provider
Networks and Infrastructure
Legislative Overview
A description of how, to the greatest extent practicable, the Secretary plans to use
infrastructure and networks of non-Department provider programs that exist as of the
date of the plan to implement such program.

Summary
Key Activities

VA currently uses a complex mix of authorities to


Enhance relationships with Federally
provide community care. Industry-leading health
funded and academic teaching
plans use streamlined practices to identify and
affiliates
recruit high-quality providers. Their networks
Support continuity of care for Veterans
with existing community providers
include an adequate number of providers in
terms of quality, mix/type of specialty, and
geographic distribution. As part of the New VCP, VA will develop a high-performing
network (See Legislative Element 10Transition Plan). This network will incorporate
existing VA relationships and develop new strategic partnerships in the community,
while adopting practices around tiered networks (see Legislative Element 6Plan to
Develop Provider Eligibility Requirements) to better serve Veterans. 39,40 Specifically,
VA plans to retain and potentially expand agreements within its Core Network,
composed of existing Federally funded partners (DoD, IHS, THPs, and FQHCs) and
academic teaching affiliates. Remaining community partners can participate in the
External Network. 41

Background and Current State


VA has agreements with approximately 40 DoD facilities (with access to TRICARE
Managed Care Contractors on a case-by-case basis), 100 IHS facilities, 80 THPs, 700
academic teaching affiliates, 700 FQHCs, 76,000 locally contracted providers, and
200,000 additional providers through the current TPAs. Despite the large numbers of
providers, VA does not have ongoing visibility into all provider locations, or an
understanding of supply and demand imbalances. Therefore, VA does not have
coverage in certain areas to provide accessible care to Veterans, or a single
39

Independent Assessment Report (Business ProcessesSection 1), Develop a long-term


comprehensive plan for provision of and payment for non-VA health care services
40 Independent Assessment Report (Health Care CapabilitiesSection 7), Streamline programs for
providing access to purchased care and use them strategically to maximize access
41 For more specific information about VAs planned use other types of existing infrastructure, please refer
to the appropriate section of the report, including Legislative Element 1 - Single Program for NonDepartment Care Delivery, Legislative Element 3 - Authorizations, Legislative Element 4 - Billing and
Reimbursement, and Legislative Element 9 - Medical Records Management

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Plan to Consolidate Community Care Programs

mechanism to actively manage provider relationships (see Legislative Element 6


Provider Eligibility).

Future State
VA intends to build a high-performing network using successful components of its
current infrastructure to meet Veterans needs (see Legislative Element 6Provider
Eligibility). 42 VA plans to retain and potentially expand agreements with the Core
Network, composed of existing Federally funded partners (DoD, IHS, THPs, 43 and
FQHCs) and academic teaching affiliates. 44 Core Network providers will be treated as a
direct extension of VA care. VA will refer patients to the Core Network before referring
them out to the External Network. 45 VA will work to develop simple and consistent
agreements with Core providers driven by quality and health outcomes.
VAs relationships with Core Network providers are unique and have evolved over time.
Sustaining and expanding Core Network relationships aligns with VAs mission, vision,
and strategies. VAs Core Network maximizes collaboration with Federal health
organizations and supports their missions. 46 DoD resource sharing agreements support
the nations defense readiness mission. Relationships with academic teaching affiliates
align with VAs education and research missions. High-quality providers in IHS, THPs,
and FQHCs promote access to exceptional care for Veterans where they live, including
rural and medically underserved communities. 47 FQHCs require rigorous quality and
risk management policies and approximately 70 percent of FQHCs have earned Patient
Centered Medical Home recognition or accreditation by the NCQA. 48
Remaining community partners meeting minimum credentialing criteria will be able to
join VAs high-performing network. They can participate in the Preferred or Standard
tiers of the External Network. The Standard tier requires only the minimum
credentialing criteria. To join the Preferred tier, these providers must also meet quality
criteria and demonstrate high-value care. VA will work to include community providers
currently serving Veterans to maintain continuity of care. Veterans can recommend
42 Other programs, such as the Camp Lejeune Family Member Program, CHAMPVA, and the Foreign
Medical Program will continue to exist separately from the New VCP
43 Refers to all Tribal Health Programs that meet CMS certification and CMS conditions of participation, or
have accreditation through the Accreditation Association for Ambulatory Health Care or The Joint
Commission, with which VA has entered a Direct Care Services Reimbursement Agreement.
44 Academic teaching affiliates have active teaching relationships with VA and are part of the VA Core
Network. Other academic institutions without teaching relationships are part of the External Network. VA
plans to retain or expand relationships under VA Directive 1663.
45 VA plans to refer patients to Core Network providers first, with exception to IHS and THPs. VA does
not currently refer patients to these institutions and does not plan on changing this arrangement.
46 VA 2014-2020 Strategic Plan
47 VA.govVA Mission and Vision Statements
48 Uniform Data System, 2014Bureau of Primary Health Care/Health Resources and Services
Administration

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existing providers for inclusion in the network and VA will work to create a simplified
provider enrollment process.
Risks and Implementation Considerations: Refer to the Transition Plan (Legislative
Element 10) section of this report.

Impact
Table 15: Impact of Network and Infrastructure
Stakeholder

Potential Impact

Veterans

VA will make it simple for eligible Veterans to choose community providers through an
inclusive network arrangement that maintains relationships with existing high-quality
health care assets. In addition, network changes will increase Veteran choice and
access to high-quality providers.

Community Providers

Core Network partners will have enhanced relationships with VA to serve Veterans.
Community providers will have a simple process for joining the External Network.

VA

VA will retain and potentially expand unique and high-priority relationships with Core
Network providers. VA will have increased visibility into supply and demand in the
network, centrally monitor provider credentialing and quality, and promote high-value
care.

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4.9

Element 9: Medical Records Management

Legislation
A description of how(A) health care providers at non-Department facilities that furnish
such care or services to Veterans under such program will have access to, and transmit
back to the Department, the medical records of such Veterans and (B) the Department
will receive from such non-Department providers such medical records and any other
relevant information.

Summary
Current VA health information exchange
practices are primarily paper-based, with manual
handoffs and inconsistent processes that create
delays. Access to current health information is
critical to supporting care coordination and
delivery of high-quality care. In the future, VA will
develop a health information environment that is
electronic, secure, efficient, effective, Veteran
centered, and standards based. 49,50,51

Key Activities
Improve consistency, simplicity, and
timeliness of information exchange
Deploy provider viewers and health
information gateway
Increase use of Health Information
Exchanges

Background
Medical records management, referred to as health information management in this
element, is the practice of acquiring, analyzing, transferring, and protecting digital and
traditional medical information vital to providing quality patient care. 52 Health
information can be divided into two categories: clinical and administrative. Clinical
information includes patient medical histories, physical findings, test results, treatments,
and clinical practice guidelines that document appropriate treatments for conditions.
Administrative information supports the business functions of health organizations and
can include medical claims, formularies, and patient referral documents. Health
systems that effectively manage health information are able to seamlessly send,
receive, locate, and access reliable and relevant information.

49

Independent Assessment Report (LeadershipSection 2), Implement a single, integrated set of


system-wide tools centered on a common EHR that is interoperable across VA and with DoD and
community provider systems
50 Independent Assessment Report (Health Information TechnologySection 3), VA should implement a
broad process, inclusive of clinicians, to pursue requirements that support clinical documentation best
practices and improved functionality and usability while considering the positive aspects of existing
systems
51 Independent Assessment Report (Data and ToolsSection 1), Use standardized clinical and
administrative data for accuracy and interoperability
52 American Health Information Management Association definition
http://www.ahima.org/careers/healthinfo?tabid=what)

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Effectively managing clinical and administrative information affects an organizations


ability to deliver coordinated, high-quality, and high-value care. Clinical information
allows providers to make well-informed diagnosis and treatment decisions.
Administrative information supports the execution of business functions, including
claims processing and reimbursement (see Legislative Element 3Authorization and
Legislative Element 4Billing and Reimbursement Systems). Additionally, operational
analytics provide data for network managers and providers to recognize public health
patterns, effective disease management programs, supply and demand trends, provider
productivity, and other information useful to improve health outcomes and operational
efficiency.
The Office of the National Coordinator for Health Information Technology (ONC) states
that despite the widespread availability of secure electronic data transfer, most
Americans medical information is stored on paper. 53 Technologies to support the
exchange of health information are quickly evolving. Two examples are Health
Information Exchanges (HIEs) and integrated web-based health information gateways.
HIE is the electronic movement of health-related information among organizations using
commonly recognized standards. HIEs facilitate access to and retrieval of clinical data
to provide safer, timelier, efficient, effective, equitable, patient-centered care. 54
Participating organizations agree to send health information to other systems, find and
request copies of health information, match patient to data, and receive updates. Key
components of an HIE are standardized legal agreements, common policies and
procedures, and technical infrastructure to securely send and receive clinical
information. HIE connectivity is increasing, but adoption is not universal. HIEs currently
reach 40 percent of U.S. hospitals and serve approximately one third of the U.S.
population. 55
Integrated web-based gateways leverage HIEs to enable health care organizations to
view and interact with both clinical and administrative information, depending on
organizational needs. Gateways can exchange documentation around claims, referrals,
authorizations of care, and critical pathways. Providers can view, append, and share
information. Common characteristics include care coordination support, electronic
information transfer, process automation, user-friendly design, use of mobile devices to
view and transfer information, and data-driven audit and evaluation.

53 Office of the National Coordinator for Health Information Technology (ONC HIT) http://www.healthit.gov/providers-professionals/health-information-exchange/what-hie
54 United States Department of Health and Human Services, Health Resources and Services
Administration (HRSA) definition
http://www.hrsa.gov/healthit/toolbox/RuralHealthITtoolbox/Collaboration/whatishie.html
55 The Sequoia Projecthttp://sequoiaproject.org/wp-content/uploads/2014/11/eHealth-ExchangeOverview-7-23-15.pdf

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Current State
VAs current process for management of health information internally and in the
community needs to simplify and improve consistency and timeliness (Table 16). In the
current state, after an appointment is scheduled, information enters the Veterans Health
Information Systems and Technology Architecture (VistA), which provides an electronic
health record (EHR) for enrolled Veterans and administrative tools. The process is
different if the Veteran is seen by a provider in the contractor networks, authorized on
an individual basis, or treated by a Federal provider in DoD or IHS.
Table 16: Current-State Limitations for Health Information Management
Current-State Limitations

Mostly manual, paper-based procedures with low EDI


Time lag for information transfer
Lack of clear definitions for information ownership at each step
Limited support for PCP care coordination
Inconsistent practices between providers
Multiple handoffs

For care through contractor networks, VA manually sends clinical and administrative
information through hard copies or fax to be uploaded to a contractor portal or
document repository. The applicable contractor provider then downloads appropriate
clinical and administrative information from the portal in preparation for the appointment.
For care through individual authorizations, VA sends information directly to providers via
print, fax, or sometimes electronic methods.
After the visit, contractors upload health information to the contractor portal and send
paper-based versions of clinical and administrative information back to VA. VA
administrative staff then manually scan and import the paper documents into VistA.
Individually authorized providers can either use the same manual practices or use VA
exchange services to transfer information back to VistA. VA exchange services
electronically exchange clinical information with community providers, including identity,
authorization and consent, and data translation functions.
After information reaches VistA from community providers (including DoD and IHS), VA
providers can then log into the Computerized Patient Record System (CPRS) or
VistAWeb applications, which allow providers to enter, review, and update Veterans
clinical information. VA staff with appropriate security credentials can view
administrative information through VistA Imaging.
VA is working on several initiatives to promote interoperability with DoD and IHS
providers, including sharing viewable data in existing (legacy) systems, developing a
virtual lifetime EHR, implementing IT capabilities for the first joint Federal health care

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center, 56 and direct secure messaging pilots. Plans also are in place to develop and
pilot tools to optimize VAs infrastructure, and VA has released mobile applications to
give Veterans and providers on-demand access to health information.

Future State
VA will adopt a phased plan consistent with a systems approach to achieve a solution
that is secure, efficient, effective, and standards based, using HIEs. Future state
systems will facilitate data transparency to promote enterprise-wide data collection,
analytics, 57 and prioritize data security. In the near-term, VA will focus on building upon
current infrastructure to improve consistency, simplicity, and timeliness of information
exchange. In the medium-term and long-term, VA plans to deploy a robust health
information gateway and services, the Enterprise Health Management Platform (eHMP),
and share most clinical information through HIEs.

Near-Term Improvements
In the near term, VA is implementing a web-based Joint Legacy Viewer (JLV) to offer a
simple, complete, and easy to understand view of VA and DoD patient data. Secondly,
VA plans to integrate existing exchange services to receive and store standards-based
electronic documents, such as Continuity of Care Documents. This reduces use of
paper and builds on current VA investments. Thirdly, VA plans to expand partnerships
with HIEs and use direct secure email protocols. Lastly, for health IT, built or bought,
VA plans to expand the usage of national standards for clinical terminology and data
elements. Community providers not using JLV or the HIEs will continue to receive
requisite health information through current state infrastructure (Table 17).
Table 17: Near-Term Improvements for Health Information Management
Near-Term Improvements

Implementation of JLV and VA exchange services (with expanded capabilities)


Use of existing infrastructure to more simply and electronically exchange information with community
providers
Integrated clinical and administrative data for metrics reporting and improved care coordination

Medium-Term and Long-Term


For all providers in the high-performing network, VA plans to create an electronic,
secure, efficient, effective, and standards-based environment in compliance with
relevant privacy laws affecting Veterans and their beneficiaries (Table 18). VA plans to
56

Electronic Health Records: VA and DOD Need to Support Cost and Schedule Claims, Develop
Interoperability Plans, and Improve Collaboration. GAO. Accessed September 30, 2015.
http://www.gao.gov/products/GAO-14-302.
57 Independent Assessment Report (Care AuthoritiesSection 5), Improve collection of data on Veteran
health care utilization and reliance

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implement a health information gateway and associated services, the eHMP, and share
most clinical information through HIEs, when available.
Table 18: Medium & Long Term Improvements for Health Information Management
Medium- and Long-Term Improvements for Health Information Management

Implementation of the Health Information Gateway and Services and the eHMP
Most clinical information shared through HIEs, increasing health information interoperability and availability
Increased support for care coordination and clearer definitions of information ownership
Support for data-driven audit and evaluation 58
User-friendly tools involving minimized use of paper-based information
Additional mechanisms to promote data privacy and security

Providers will be able to view, append, and share clinical and administrative information
electronically through a VA health information gateway and associated services
(Figure 6). Veteran clinical and administrative information will then be transferred back
to VistA. VistA will incorporate an industry-leading information model, terminology
normalization, knowledge enrichment, and search indexing for VA, Federal, and HIE
partner sources. Available health information will drive enterprise-wide analytics efforts
for process improvement.
Specifically, the health information gateway and services will include integrated point-ofcare applications for Veterans, community providers, and staff. Services refer to
technologies that facilitate privacy and security, data translation, and data storage. VA
will create a data-driven evaluation process for provider adherence to VA critical
pathways to promote high-quality and high-value care.
VA will deploy the eHMP in the medium-term, which will replace CPRS and include JLV
capabilities. eHMP will integrate end-user clinical encounter and care coordination
transaction capabilities, data visualization, and decision support services. eHMP will
feature a common electronic care plan with standardized protocols tailored to individual
Veteran needs. Information gathered through patient-facing and telehealth technologies
will update the care plan (see Care Coordination for additional detail).
VA will share most clinical information through HIEs and work with ONC, national
standards organizations, and industry associations to move toward full standardization
of health IT components. VA will use national standards for data elements such as
labs, medications, allergies, and vitals. Data interoperability standards will promote
seamless handoffs of more complete patient records between VA and community
providers.
58

Expanded data and reporting documentation to include Affordable Care Act data collection standards:
http://aspe.hhs.gov/basic-report/hhs-implementation-guidance-data-collection-standards-race-ethnicitysex-primary-language-and-disability-status will be included to meet VHA Strategic Goal 1E

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Figure 6: Diagram of Medium- and Long-Term Improvements for Health Information


Management
Risks and Implementation Considerations: Refer to the Transition Plan (Legislative
Element 10) section of this report.

Impact
Table 19: Impact of Medical Records Management Requirements
Stakeholder

Potential Impact

Veterans

Veterans will benefit from better care coordination due to the ease of clinical and
administrative information flow between VA and community providers.

Community Providers

Community providers will benefit from quick, user-friendly processes for accessing
and submitting clinical and administrative information. Improving the community
provider experience could incentivize additional providers to join VAs network.
Timely access to clinical information can lead to more informed decisions to improve
quality of care.

VA

VA providers will also benefit from ease of access to clinical information on their
patients. Improved access to clinical data can lead to improved care coordination
and clinical decision-making. VA will benefit from automating practices and using
common standards, legal agreements, and governance, which can reduce
administrative costs and promote higher-quality care delivery for Veterans. Applying
analytics to health information can show public health patterns, effective disease
management, and ways to use resources more effectively.

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4.10 Element 10: Transition Plan


Legislation
A description of how the Secretary plans to ensure an efficient transition to such
program for Veterans who participate in the non-Department provider programs,
including a timeline, milestones, and estimated costs for implementation, outreach, and
training.

Background
The New VCP is a key component of how VA will deliver care in the future. Currently,
VA has multiple disconnected systems and processes to perform clinical and
administrative functions for purchasing care. This is inefficient and causes confusion
among Veterans, community providers, and VA staff. Under the New VCP, these
disparate systems and processes will be consolidated and streamlined into an
integrated system for a seamless experience for all stakeholders. In addition, as this
plan is reviewed and updated to incorporate input from Congress and other
stakeholders, the activities and resources required to consolidate community care
programs will likely be impacted.
The New VCP will be implemented through a system of systems approach. As outlined
in the Introduction to this report, a system of systems approach involves the design,
deployment, and integration of meta-systems that are themselves composed of complex
systems, which are integrated to deliver the desired functionality and end-to-end user
experience. 59 Consistent with this approach, VA will begin by understanding the
desired experience and required outcomes for Veterans, caregivers, VA staff, and
community providers. VA will then examine all the components necessary to achieve
the desired outcomes and understand how various component systems will integrate
into the broader VA health care system and funding environment. To successfully
implement this system of systems approach requires legislative changes, resources and
budget. Requested changes are outlined in the Estimated Costs and Budgetary
Requirements (Section 5) and Legislative Proposal Recommendations (Section 6) of
this plan. If legislative changes are not provided within the requested timelines, it will
adversely affect VAs ability to deliver the New VCP as described in this plan.
Implementation of the system of systems approach will be executed through rapid cycle
deployment using agile methodologies. This will allow VA to fix the most pressing
issues with community care today, while making continuous updates to promote a
learning health system that evolves with the needs of the Veteran population. This
approach enables VA to implement an integrated system design that allows people,
59

Adapted from: Lia, P., Fisk, R. P., Falco e Cunha, J., & Constantine, L. (2011). Multilevel service
design: From customer value constellation to service experience blueprinting. Journal of Service
Research, 14(2), 180200.

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processes, facilities, equipment, and organizations to deliver high-quality, high-value


care.
Based on preliminary analysis of Veteran needs and the desired Veteran experience,
VA has determined that the component systems of the New VCP are 1. Integrated
Customer Service Systems; 2. Integrated Care Coordination Systems; 3. Integrated
Administrative Systems (Eligibility, Patient Referral, Authorization, and Billing and
Reimbursement); 4. High-Performing Network Systems; and 5. Integrated Operations
Systems (Enterprise Governance, Analytics, and Reporting). These systems align to
the five functional areas of the New VCP, as well as include customer service, change
management, program management/enterprise governance, and data collection,
analytics, and reporting activities that are critical to successful implementation (Table
20).
Table 20: Alignment of New VCP Functional Areas to Component Systems
Component Systems

Functional Area(s)

1. Integrated Customer Service Systems

Customer Service

2. Integrated Care Coordination Systems

Care Coordination

3. Integrated Administrative Systems (Eligibility,


Patient Referral, Authorization, and Billing and
Reimbursement)

Veterans We Serve (Eligibility)


Access to Community Care (Referral and
Authorization)
Provider Payment (Claims)

4. High-Performing Network Systems

High-Performing Network

5. Integrated Operations Systems (Enterprise


Governance, Analytics and Reporting)

Change Management
Program Management/Enterprise Governance
Data Collection, Analytics, and Reporting

In order to execute a program of this scope and scale, VA has outlined a transition plan
consistent with the system of systems approach to sequence the design, development,
and delivery of the New VCP. In developing the transition plan, VA considered
recommendations from stakeholder feedback and the Independent Assessment Report.
While the transition plan lays out a path forward for the program, the complexity of the
change will require development of detailed implementation plans. In addition, any
changes to the New VCP described in this plan as a result of input from Congress or
other stakeholders will impact the activities described.

Structure of the Transition Plan


Transitions of this magnitude take years to design and implement; therefore, this plan is
organized into three phases. Phase I can start immediately and will last one year,
assuming available resources and required legislative and regulatory changes. This
phase will focus on the development of minimum viable systems and processes that
can meet critical Veteran needs without major changes to supporting technology or
organizations. In Phase II, also lasting approximately one year, VA will enhance the

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changes implemented in Phase I through interfaced systems that will appear seamless
to Veterans and community providers, but will largely continue to employ existing
infrastructure and technology. Phase III will be a multi-year effort. For the purpose of
this report, only the first year of Phase III has been outlined. In Phase III, VA will begin
deploying an integrated system of systems that will support changes in Phases I and II
and enable a seamless experience across VA and community care for all stakeholders.
VA also will collect and analyze data on the progress and performance of the
implementation to identify opportunities for continuous improvement. Overall, through
all phases of the transition, VA will build a foundation for a health care system that can
respond to the evolving needs of Veterans and the changing health care landscape at
VA and in the community. Figure 7 outlines representative requirements for each
component system in each phase, illustrating how each phase will build on the previous.

Figure 7: Phased Approach to the New VCP


Phase I: Develop Implementation Plan and Implement Minimum Viable Solutions
and Processes
During Phase I, VA will develop an implementation plan that articulates a clear path
forward for each system component across the three phases. This will include
decisions about long-term system changes and outcomes of make/buy analyses for
clinical and administrative technology solutions and network development. Phase I will
also include the implementation of minimum viable systems and processes for the
Veteran, community provider, and VA staff experience. These systems will focus on
improvements that can be executed without major changes to organizations or
technology. Key Phase I requirements include:

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1. Integrated Customer Service Systems:


Align with MyVA customer service infrastructure to improve the Veteran and
community provider experience.
Develop and implement communication plans for Veterans, community providers,
and VA staff on initial changes.
2. Integrated Care Coordination Systems:
Evaluate Veteran needs for care coordination.
Evaluate existing programs to identify alignment with Veteran needs and
evaluate opportunities to optimize the portfolio.
3. Integrated Administrative Systems (Eligibility, Patient Referral, Authorization,
and Billing and Reimbursement):
Define, implement, and communicate consistent eligibility requirements for the
New VCP to improve access to care and reduce stakeholder confusion.
Determine list of services requiring clinical authorization.
Simplify referral and authorization processes to enable consistent and efficient
access to care.
Dedicate additional resources to reducing claims backlog and develop plans to
bring VA performance and metrics into greater compliance with PPA.
4. High-Performing Network Systems:
Standardize agreements with Federally funded partners, academic teaching
affiliates, and existing community providers.
Develop initial requirements for participation in Core and Preferred networks to
support development of the high-performing network.
Use analytics to identify network gaps.
5. Integrated Operations Systems (Enterprise Governance, Analytics, and
Reporting):
Develop detailed implementation plan, schedules, governance structure, and
milestones to support transition.
Develop appropriate communications and training for VA staff on changes to
community care systems and processes.
Phase II: Implement Interfaced Systems and Process Changes
During Phase II, VA will implement interfaced systems and associated processes that
will enable a seamless experience for Veterans and community providers. Interfaces
will employ existing resources and technology infrastructure, but will appear integrated
to end users. Simultaneously, VA will continue to develop fully integrated solutions that
will be deployed in Phase III. Key requirements in this phase include:

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Plan to Consolidate Community Care Programs

1. Integrated Customer Service Systems:


Continue to communicate with Veterans and community providers about the New
VCP.
Implement customer service metrics to evaluate and improve performance.
2. Integrated Care Coordination Systems:
Implement continuum of care coordination with levels appropriate to Veteran
needs.
Expand care/disease coordination programs and align support roles.
Enable medical record sharing between VA and community providers.
Begin to analyze Veteran data to identify triggers and registries for intervention
and communications about specific programs.
3. Integrated Administrative Systems (Eligibility, Patient Referral, Authorization,
and Billing and Reimbursement):
Centralize authorization review.
Refine requirements and execute claims solution.
Implement standardized claims processes and metrics to achieve greater Prompt
Payment compliance.
4. High-Performing Network Systems:
Analyze Veteran eligibility and usage data to identify coverage gaps.
Implement provider credentialing and audit processes to evaluate network
consistency and quality.
5. Integrated Operations Systems (Enterprise Governance, Analytics, and
Reporting):
Continue to manage program budget and update schedules and milestones.
Evaluate change management and communicate impacts of process changes to
VA staff.
Phase III: Deploy Integrated Systems, Operate High-Performing Network, and
Make Data-Driven Improvements
During Phase III, VA will begin to deploy integrated systems, including process and
organization changes that will enable a seamless Veteran, community provider, and VA
staff experience. These systems will build on changes in Phases I and II and will
support collection of quality, value, and performance data for continuous improvements.
Key requirements in this phase include:
1. Integrated Customer Service Systems:
Deploy a single customer service solution and analyze customer service data to
support continuous improvements.

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Plan to Consolidate Community Care Programs

2. Integrated Care Coordination Systems:


Implement systems to monitor quality of care in accordance with Federal and
industry standards.
Continue to evaluate care/disease coordination programs to assess outcomes
and identify additional needs.
Use Veteran data to trigger outreach for care/disease coordination programs and
evaluate success.
Improve appropriate information sharing for Veterans care between Veterans,
community providers, and VA staff.
Deploy health information gateway and services to facilitate community provider
interaction with VA.
3. Integrated Administrative Systems (Eligibility, Patient Referral, Authorization,
and Billing and Reimbursement):
Deploy single eligibility solution supporting Veteran self-service. Continue to
evaluate and update eligibility criteria to meet Veteran needs.
Deploy integrated referral and authorization system that integrates with claims
system, and enable Veteran and provider self-service.
Deploy new claims solution that supports auto adjudication and Prompt Payment
compliance.
Utilize emerging value-based reimbursement methodologies.
4. High-Performing Network Systems:
Continue to expand network, minimize coverage gaps and increase number of
Preferred providers for greater Veteran choice.
Begin to apply quality-and value-based payment methodologies in the network.
5. Integrated Operations Systems (Enterprise Governance, Analytics, and
Reporting):
Continue to manage any changes to funding, schedules, or milestones.
Integrate change management and communicate changes to the program to
affected stakeholders as they occur.

Detailed Transition Requirements by System


The section below details key requirements for the New VCP. The section is structured
around the systems described in Table 20. It provides outcomes and key requirements
for each system throughout the three phases of implementation.
1. Integrated Customer Service Systems:

Purpose: Improve the Veteran and community provider experience with


community care.

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Plan to Consolidate Community Care Programs

Key Requirements:
Customer Service Solutions: VA will use customer service solutions aligned
with MyVA to provide prompt, responsive customer service for the New VCP.
Over time, this will include the definition of robust, outcome-focused customer
service metrics that will inform regular evaluation and improvements to the
process.

2. Integrated Care Coordination System:

Purpose: Improve Veteran health outcomes through better care coordination.

Key Requirements:
Consolidate care management system: Design a consolidated care
management system to standardize care coordination activities, analyze
additional care and disease management needs, and evaluate the quality of
care provided.
Communicate a consistent care coordination model: Conduct a care
coordination assessment to develop care coordination policies and
procedures. Enhance existing pilot programs to improve Veteran health
outcomes and models and begin piloting case management/disease-specific
programs. Integrate programs with the health information gateway for
community providers.
Improve information sharing: Design a system to facilitate the sharing of
medical records between providers using standards and terminology to
support interoperability. Continue to expand medical records access and
clinical information sharing via HIEs.
Apply analytics to identify target populations for care programs: Use
data to identify Veterans for disease/case management programs. Conduct
outreach to VA staff, community providers, and eligible Veterans to increase
awareness.

3. Integrated Administrative Systems (Eligibility, Patient Referral, Authorizations,


and Billing and Reimbursement):

Purpose: Reduce access barriers and streamline administrative processes for


community care.

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Key Requirements:
Eligibility:

Define eligibility for the New VCP: Define and communicate eligibility
to promote convenient access for Veterans, and reduce confusion
among Veterans, community providers, and VA staff. This will include
communication to key stakeholders regarding the impact of the New
VCP and revised eligibility requirements.

Enable data-driven changes to eligibility: Regularly evaluate new


eligibility criteria, policies, and stakeholder experience to understand
whether criteria are meeting Veteran needs. Make necessary
changes, update stakeholder materials to reflect changes, and
communicate with stakeholders to eliminate confusion.

Consolidate eligibility systems: Provide clear visibility into Veteran


eligibility for the New VCP by using an integrated system. The system
will automate determinations, update Veteran eligibility (e.g., if a
Veteran is added to a wait list for care or relocates), and integrate with
other VA eligibility and claims systems.

Referral and Authorization:

Streamline referral and authorization: Simplify and streamline


referral and authorization systems, including the development of a
single list for services that require authorization. Communicate
changes to affected stakeholders.

Centralize authorization functions: Determine requirements for


consistent implementation of a standard authorization system across
facilities. Design appeals policies and procedures and a process to
evaluate and update authorization lists. Establish a Referral
Coordinator role to assist Veterans with identifying and accessing
community providers.

Integrate referral and authorization solution: Define requirements


and implement new integrated systems, enabling the collection and
analysis of necessary data for care delivered in and outside of VA
facilities. Utilize data to identify areas for improvement and refine the
process.

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Plan to Consolidate Community Care Programs

Billing and Reimbursement:

Eliminate claim-processing backlog: Dedicate sufficient resources


for oversight of inventory to eliminate the current claims backlog. Align
to industry payment standards.

Implement new claims processing solution: Identify requirements to


receive all claims electronically to enable auto adjudication of claims
and increase efficiency through integration with other VA systems.
Evaluate ability to add other programs (e.g., CHAMPVA) to the solution
as efficiencies are gained.

Align metrics with the PPA: Continuously monitor the progress of


reducing the claims backlog and use data analytics to understand
claims volume and determine productivity standards. Continue to
disseminate standardized claims-processing policies and procedures
and establish metrics that support Prompt Payment compliance.

4. High-Performing Network Systems:

Purpose: Increase Veterans access and choice in community providers.

Key Requirements:
Develop a high-performing network: Identify core competencies and
gaps in current networks and develop a high-performing network with the
features described in this report. Continue to conduct analyses to identify
network gaps and define utilization standards that are consistent for
network and VA for providers. Establish necessary systems to support a
high-performing network and develop communications for stakeholders.
Standardize provider eligibility criteria: Develop policies and
procedures to improve operational efficiency, including standardizing fee
schedules, delegating credentialing, contracting, and continuously
evaluating processes and policies for further improvements. Support
identification of high-performing network providers using data analytics
and uniform standards.
Adopt quality and value-based payment methodologies: Support
value-based payments for community providers using emerging models
from industry.

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Plan to Consolidate Community Care Programs

Improve solutions to support the provider network: Design systems to


maintain up-to-date registration and management of the community
provider network, including tracking of performance metrics and
compliance with provider eligibility criteria. Enable Veterans to choose a
network provider based on clinical need and convenience, and create a
provider experience that makes VA a desirable partner in care.
5. Integrated Operations Systems (Enterprise Governance, Analytics, and
Reporting):

Purpose: Enable the successful implementation of the New VCP through


program governance and leadership visibility into care quality and program
performance.

Key Requirements:
Establish Governance and Management for the New VCP: Establish
local and national management for community care. Standardize
management structures for community care within facilities and establish a
new DUSH for Community Care to support a consistent Veteran
experience with the New VCP. Develop a schedule, milestones, and
budgets to support implementation of the New VCP and promote
integration with the VA health care delivery system. Develop
comprehensive communication and training materials for all stakeholders
on changes to VA systems, policies, and procedures.
Analytics and Reporting: Support decision making by improving
information and transparency to optimize health outcomes, analytics, and
program management. Evaluate options for a consolidated reporting
solution for the New VCP to aggregate and standardize data and conduct
necessary analysis.

Transition Considerations and Risks


The successful implementation of the New VCP transition plan will require new
legislative authorities and identification of appropriate resources. This section outlines
key considerations and risks that could affect VAs ability to implement the transition
plan outlined above. High-level considerations include:

Legislative Authorities: As VA begins to consolidate community care into the New


VCP, the Department will need several new authorities to improve access to care
(e.g., the ability to consolidate existing programs). Some of these authorities are
critical to program stand-up and are needed immediately, while others are not
necessary until later in the transition. If these authorities are not provided within the

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requested timeline, VA will not be able to fully execute the New VCP. For additional
information regarding requested legislative authorities, please refer to the Legislative
Proposal Recommendations section of this report.

Funding: To support the New VCP, VA will need to deploy the integrated system of
systems described above. This deployment also will require a significant change
management effort, including communications and training. To implement this
transformation, VA will need additional funding. If funding for the changes proposed
in this report is not provided, it will affect VAs ability to deliver the New VCP as
described in this report. For additional information regarding requested funding,
please refer to the Estimated Cost and Budgetary Requirements section of this
report.

Timelines: The estimated times for completion of phases described in this transition
plan are aggressive and intended to position VA to implement streamlined
processes and meet the care needs of Veterans quickly. If legislative and budgetary
requests are not approved, or the New VCP does not receive appropriate support
from internal and external stakeholders, these timelines may be adversely affected.

Culture Change: The New VCP is a major change for VA and will require Veterans,
VA staff, and community providers to embrace community care as an integral
element of the VA health care system. If the program implementation or change
management efforts are not well planned or managed, stakeholders may not buy in
to the change, adversely affecting the programs chances of success.

Innovation: Health care management practices continue to evolve, especially the


use of information technology for measurement, analytics, computer-assisted clinical
decision making and Veteran self-help. Over time, plans for the New VCP may need
to be adjusted to accommodate the latest innovations in health care.

Stakeholder Input and Buy-In: The New VCP described in this plan is notional and
represents VAs perspective on the path forward for VA Community Care. Congress
and other stakeholders will have input into the final design of the program. If input
from stakeholders requires modifications to the New VCP as described in this plan,
the transition plan and associated timelines may need to be updated to account for
these changes.

In addition to these higher-level considerations, there are a number of more specific


risks that VA has identified which have the potential to affect the successful transition to
the New VCP (Table 21). To facilitate mapping to the previous sections of this report,
risks are aligned to the Legislative Elements. In some cases, Legislative Elements have
been combined if risks are consistent across elements.

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Table 21: New VCP Transition Risks


Legislative
Element
Element 1: Single
Program for NonDepartment Care
Delivery

Risks

Mitigation Strategies

Challenges in integrating existing


community care contracts and VA
care, and methods to give Veterans
the experience of a single program

Prioritize areas with direct Veteran impact in initial


efforts to introduce consistency

Potential for further


compartmentalization of activities as
community care functions are
consolidated under a new DUSH for
Community Care

Develop regular touchpoints and communications


between new DUSH and other affected areas of
VHA. Understand and communicate areas of
community care that require integration with other
VHA functions. Foster an open and collaborative
culture for the New VCP. Implement consistent
performance metrics for VA providers and network
providers

Inability to cope with initial customer


inquiry volume as New VCP is
implemented

Provide surge staffing at customer service centers


to support prompt responses to initial Veteran
inquiries; implement robust communications
campaign; unify message content at all customer
service centers

There will be initial Veteran confusion


on individual eligibility for community
care under the New VCP

Develop targeted outreach and prepare customer


service centers with clear scripts explaining the
program. Develop and implement consistent
guidance on eligibility determinations, education,
training, and communication across facilities

New Emergency Treatment and


Urgent Care eligibility criteria and
guidance will be susceptible to fraud,
waste, and abuse

Develop business rules to trigger audit of


emergency treatment and urgent care claims to
identify potential overuse or fraud, waste, and
abuse of these services

There may be significant logistical


challenges associated with
developing a central authorization
center

VA could leverage existing resources from


streamlined processes to staff the centralized
authorization center

The authorization process is not well


tied to the referred consult, creating
confusion or wait-time for Veterans

VA will develop and deploy standard business


rules, performance benchmarks to monitor and
continuously improve the Veteran experience while
using automation of referrals to scheduling

Network providers are not all


educated on the revised referral and
authorization process

VA will educate providers on a recurring basis to


support existing and new providers in VA and the
community using technology

Element 4: Billing
and
Reimbursement
Process

Auto adjudication of clean claims


may increase the potential for health
care fraud

Increase investment in business compliance and


oversight capabilities, including computerized
methods to detect potentially inappropriate activity.
Consider a mechanism similar to Medicares
Recovery Audit Contracts

Element 5:
Provider

Performance standards are not


case-mix adjusted, driving providers
to optimize through lower-risk cases

VA can use more developed metrics and incentive


models initially (e.g., CMS developed) to be
consistent with industry direction and clinical

Element 2:
Patient Eligibility
Requirements

Element 3:
Authorization

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Plan to Consolidate Community Care Programs

Legislative
Element

Risks

Mitigation Strategies

Reimbursement
Rate

Element 6: Plan
to Develop
Provider Eligibility
Requirements
Element 8: Plans
to Use Current
Non-Department
Provider
Networks and
Infrastructure

relevance to account for case mix complexity, and


incentivize providers to take on high risk patients

Claims processes and rate schedules


are not integrated effectively creating
issues with meeting Prompt Payment
rules

VA can tightly integrate claims configuration and


payment schedules as it implements a revised
claims-processing approach and value-based
payment models. VA can analyze payments
routinely to confirm consistency

Variation in provider quality


metrics/outcomes as new models and
processes are implemented

VA can establish CMS and industry-consistent


guidelines across VA and network providers and
reinforce behavior through metrics reporting and
payment models

The transition from traditional fee for


service to value-based payments is
not well understood and providers
may not perform as expected initially

Value-based re-imbursement will closely mimic


CMS implementation; craft a communications plan,
including explanations on VAs industry-consistent
direction and expectations well in advance of
implementation

High-performing provider network


may not have adequate coverage to
serve Veterans (e.g., geographic
distribution and specialties)

Research network supply and demand needs using


real-time and predictive analytics and develop
relationships with providers/institutions serving rural
and underserved communities (e.g., FQHCs). Be
upfront about regional variation with Congress and
VSOs.

Veterans may be unable to


consistently assess provider
performance and credentialing status
due to inconsistent standards
between VA and industry

Work to develop consistent quality and credentialing


standards within the high-performing network,
aligned to industry processes

Community providers may not be


educated about military culture and
issues affecting Veterans

Encourage providers in the high-performing network


to take trainings, use available educational
resources, and collaborate directly with experienced
VA providers

Current community network providers


may not want to join the
high-performing network due to
challenges in the past

Create a process that makes it simple for providers


to enter the network, in addition to a simple
transition process for existing providers; create
timely claims processing capability; implement
financial incentives to attract providers

Unclear ownership of network


management functions and personnel
are not appropriately trained

Designate clear roles for industry-leading network


management functions (as they relate to core,
standard, and Preferred providers) and ensure
personnel are well-trained

Inconsistent management of provider


data and lack of visibility into
operations

Create centralized data management function,


consistent data management processes, and a
common source for New VCP data

Maturity of local health networks and


ACOs varies across the nation

Be transparent about regional variation with


Congress and VSOs. Allow limited experimentation

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Plan to Consolidate Community Care Programs

Legislative
Element

Risks

Mitigation Strategies
with different models at the state level that does not
impact the Veteran experience from site to site

Anticipated provider shortages,


especially for primary care and Mental
Health, particularly in areas of
greatest need

Be transparent about the regional variations that will


exist, particularly for primary care.

Element 7:
Prompt Payment
Compliance

Lack of sufficient resources to reduce


claims backlog and meet Prompt
Payment guidelines

Develop and implement training for claimsprocessing staff. Develop clear strategy to reduce
the claims backlog. Create incentives to increase
electronic submission of claims

Element 9:
Medical Records
Management

Risk of data breach or other security


issues involving Veteran personally
identifiable information or protected
health information

Research, select, and implement best practices for


data privacy and security across people, process,
and technological areas (e.g., permissions and
cyber threat detection)

Health information management tools


and technologies are created without
a cohesive strategy nor awareness of
ongoing initiatives

Consistent communication about ongoing initiatives


and development of cohesive strategy with
appropriate stakeholders focused on both process
an outcome measurement

Process and technology changes are


not well-integrated into provider/staff
workflows, in addition to Veteran
workflows

Prioritize consistent transition planning efforts for


affected stakeholders; use process mapping
techniques to facilitate integration of tools and
clinical workflow

Lack of coordination and


communication with DoD and IHS
health information leadership to
promote interoperability

Consistently communicate with appropriate


contacts, agree upon data models and standards,
and coordinate deadlines

Lack of defined process owners for


health information management
processes

Clearly define process owners, educate owners,


and perform appropriate policy development and
transition planning efforts

Organizational capacity to implement


major transformational change is
severely limited. The New VCP could
demand so many resources that VA
loses attention to current operations

Fold activities into the overall reform of the VA


health care system, integrated with MyVA. Use the
Commission on Care to help prioritize activities.
Consciously link the New VCP action plans to what
is proposed in response to the Independent
Assessment Report; use industry best practices for
change management

Timelines for the acquisition process


may affect the delivery of some
aspects of the Program

Develop anticipated list of RFPs as part of detailed


implementation planning. Initiate the contracting
process early to limit delays. Use early collaboration
with acquisition community to structure RFPs in
optimal way to avoid re-work

Constrained IT resources may affect


VAs ability to deliver technology
system components along proposed
timelines

Collaborate with VA Office of Information and


Technology (OI&T) to develop an understanding of
the IT needs and timelines

Element 10:
Transition Plan

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Plan to Consolidate Community Care Programs

Legislative
Element

Risks

Mitigation Strategies

Hiring and retaining qualified staff is


critical to the successful delivery of
the program

Encourage staff ownership of the Program. Foster


an open and innovative culture that promotes
personal and professional growth

Changing political winds could derail a


multiyear initiative that will span many
administrations and Congressional
elections

Use the Commission on Care and other vehicles to


push legislation that helps to insulate VA from
short-term political considerations. Seek multiyear
authorities, including ability to give key leadership
positions (e.g., DUSH for Community Care), a
tenure that will span administrations

Inability to attract the caliber of


leadership and expertise needed to
achieve successful implementation
under Federal pay schedules

Consider extent to which Title 38 hiring and


compensation authorities should be expanded to
include health system and health plan
administrators.

Developing the analytic and big data


capabilities that a plan of this scope
needs will take years of investment
and is unlikely in the current IT
environment and budget

This is predicated on a successful response to


Independent Assessment H.

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Plan to Consolidate Community Care Programs

5.0

Estimated Costs and Budgetary Requirements

Legislative language
Estimated costs and budgetary requirements to implement the plan and to furnish
Hospital Care and Medical Services pursuant to such plan.

Introduction
Consolidating purchased care programs is critical for the long-term success of VA as an
integrated care delivery system. Currently, VA has multiple disconnected processes to
perform clinical and administrative functions associated with purchasing care. In
addition, there are multiple legal authorities with different criteria and business rules for
the various purchased care programs. This variation causes confusion among
Veterans, community providers, and VA staff. Under the New VCP, these disparate
authorities, business rules, processes, and systems will be consolidated into a single
program that supports the future vision of VA outlined in this plan.
A transformation of this scale requires VA to take a system of systems approach,
examining all the components of the system and optimizing desired outcomes, rather
than trying to optimize component parts. This approach must take a holistic view of
Veteran care and consider changes that affect care both inside the VA and in the
community. Using this approach, VA has identified required changes to five clinical and
administrative systems: Integrated Customer Service Systems, Integrated Care
Coordination Systems, Integrated Administrative Systems (Eligibility, Patient Referral,
Authorization, Billing, and Reimbursement), High-Performing Network Systems, and
Integrated Operations Systems (Enterprise Governance, Analytics, and Reporting).
Delivering the New VCP will not be successful without approval of requested legislative
changes and required budget. Discussion of the estimated budget increase associated
with implementing this plan is divided below into three sections: (1) System Redesign
and Solutions; (2) Hospital Care and Medical Services, including Dentistry; and (3)
Expanded Access to Emergency Treatment and Urgent Care. System Redesign and
Solutions include enhancements to the referral and authorization process, care
coordination and customer service, and claims processing and payment. These
changes are expected to improve the Veteran experience with community care. This
may result in an increase Veteran reliance on VA community care, leading to the
increased health care costs described in the Hospital Care and Medical Services
section. Expanded Access to Emergency Treatment and Urgent Care is important in
providing Veterans with appropriate access to these services, but is severable from
other aspects of the program and could be implemented separately. This section
details the estimated budget increase associated with the each area described above,
as well as the methodologies and assumptions used in generating the estimates. Note
that the cost estimates in this section represent incremental increases above VAs

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Plan to Consolidate Community Care Programs

existing Community Care program, which includes historical costs of hospital care,
medical services, and long-term services and supports (approximately $7 billion a year
in the base budget), and assumes the continuation of the existing Veterans Choice
Program with no modification (approximately $6.5 billion additional cost annually).

Budget Estimation Methodology


System Redesign and Solutions budget estimates primarily refer to one-time costs of
the System Redesign and Solutions delivery. Focus areas for system improvements
included in the budget estimate relate to enhancements in the referral and authorization
process, care coordination and customer service, and claims processing and payment.
Estimates were created by joint business and IT workgroups to identify incremental
costs associated with New VCP requirements. Given the short time frame required to
produce this report, these estimates should be considered as rough order of magnitude
estimates. Detailed requirements and/or validation with key stakeholders and SMEs are
ongoing and necessary to refine these estimates.
VA estimated the Health Care Services Costs (Hospital Care and Medical Services,
including Dentistry and Expanded Emergency Treatment and Urgent Care) using the
VA Enrollee Health Care Projection Model, base year 2014. The New VCP is not
expected to affect Health Care Services Costs in Phase I, so it will have minimal impact
on the Health Care Services budget for that time period. Anticipated Health Care
Services Costs for Phase II and year one of Phase III are incremental above VAs
existing Community Care program, which includes historical costs of hospital care,
medical services, and long-term services and supports (approximately $7 billion a year
in the base budget), and assumes the continuation of the existing Veterans Choice
Program with no modification (approximately $6.5 billion additional cost annually).
All costs described in this section are estimates. These estimates may increase based
on additional analyses, as a result of increased demand for VA health care, or as a
result of changes to the design of the New VCP based on input from Congress or other
stakeholders.

Incremental Cost of New VCP System Redesign and Solutions


The estimated incremental cost increases associated with the redesign, development,
and delivery of systems and technology solutions for the New VCP are outlined in
Table 22. The majority of these estimates primarily refer to one-time costs of System
Redesign and Solutions. Over time, these system improvements are likely to result in
cost savings as process efficiencies are realized (e.g., reduced timelines for eligibility
determinations and increased auto-adjudication of claims).

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Table 22: Estimated Incremental Costs for New VCP System Redesign & Solutions

New VCP System Redesign and Solutions


costs (not Health Care Service related)

Phase I
Incremental
($ M)
$ 421

Phase II
Incremental
($ M)
$ 606

Phase III: Year 1


Incremental
($ M)
$
851

Key considerations for the System Redesign and Solutions cost drivers are outlined
below:

Incremental Cost EstimatesMany of the System Redesign and Solutions


outlined above build upon existing improvement projects already underway at VA
(e.g., medical records transfer and care coordination systems). The joint
workgroups considered the scope, expected timeframes, and funding streams of
these projects when developing the incremental costs for the New VCP.
Make/Buy DecisionsSeveral systems and solutions will require VA to complete a
Make/Buy analysis for a final recommendation. This report begins to identify
enablers and requirements, but does not make any recommendation for Make/Buy
decisions. The outcome of these recommendations will have an impact on the final
cost.
Key Project DependenciesThe New VCP is dependent on several improvements
currently being developed by other areas of the Department. For example, updating
customer service telephone infrastructure and implementing a financial management
solution will be foundational to the New VCP. The costs of these key projects are
accounted for elsewhere and not included in this analysis.
Limiting Scope of Delivery for Existing Programs Some programs already in
developmentspecifically Virtual Lifetime Electronic Record and the eHMP will
need to be modified based on the requirements for the New VCP. Incorporating
requirements for the New VCP into these programs early in their development may
reduce the long term costs of system modifications. However, this incorporation will
likely increase short term costs.

Incremental Cost of New VCP Hospital Care and Medical Services Eligibility
The Hospital Care and Medical Services, including Dentistry, eligibility criteria for the
New VCP do not represent a significant change from the eligibility criteria outlined in
The Choice Act and the VA Choice and Budget Improvement Act. For example, the
New VCP preserves access to community care based on wait-time and geographic
access/distance criteria, the more detailed excessive burden guidance, and recent
removal of the requirement of enrollment prior to August 2014. Despite minimal
changes in eligibility criteria, an increase in Veteran reliance on VA community care is
expected as System Redesign and Solutions described above meaningfully improve the
Veteran experience with community care. The estimates in Table 23 below document

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Plan to Consolidate Community Care Programs

the expected incremental costs, which are primarily associated with (1) an increased
reliance on VA for those eligible under the Geographic Distance/Convenience criteria,
(2) a shift to Medicare Fees Schedules, and (3) Revenue Offsets.
Table 23: Estimated Incremental Costs for New VCP Hospital Care and Medical
Services Eligibility Changes
Phase I
Incremental
($ M)

Phase II
Incremental
($ M)

Phase III: Year 1


Incremental
($ M)

New VCP - Hospital Care and Medical


Services Medical and Administrative Cost

2,064

2,318

New VCP - Hospital Care and Medical


Services Revenue Offset

(205)

(171)

New VCP - Hospital Care and Medical


Services Changes Total Net Cost

1,859

2,147

Key considerations for Hospital Care and Medical Services Eligibility are outlined below:

Initial Cost Drivers: Health care costs for the New VCP are primarily driven by an
increased reliance on VA for those eligible under the Geographic
Distance/Convenience criteria, a shift to regional Medicare Fees Schedules, and
increased Revenue Offsets from Veteran OHI.
- Geographic Distance/ConvenienceThe New VCP Geographic
Distance/Convenience eligibility criteria offer enrolled Veterans who live more
than 40 miles from a VA PCP access to community care. Because of
enhancements in customer service and care coordination proposed under the
New VCP, a greater demand for community care is anticipated from this
population. VA assumed that the reliance of the enrollee population originally
eligible under The Choice Act (approximately 600,000) will increase to 50 percent
from roughly 37 percent anticipated in 2017. In addition, for all enrollees eligible
under The Choice Act and The Veterans Choice and Budget Improvement Act
(approximately 900,000), approximately half of the care they would have been
expected to receive in VA facilities under their historical level of reliance is
expected to move to the community through the New VCP.
- Medicare Allowable CostsCost estimates for the New VCP assume that VA
will pay regional Medicare rates, plus typical administrative costs for health care
services provided through the program. Because some community care has
traditionally been purchased above these rates, this change will lead to a
decrease in the cost of community care.
- Revenue Offset Increased Veteran utilization of community care as a result of
New VCP System Redesign and Solution Improvements will, in some cases, lead

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Plan to Consolidate Community Care Programs

to increased collections from Veteran OHI. These collections will offset some of
the health care services costs.

Incremental Cost of New VCP Expanded Access to Emergency Treatment


and Urgent Care
The current eligibility criteria for seeking emergency treatment through community care
are extremely complex and require nuanced determinations for individual claims. These
criteria lead to a large number of denied claims and confusion among Veterans about
when they are eligible to receive emergency treatment through community care. The
New VCP identifies improvements in access to emergency treatment and urgent care in
the community. To encourage appropriate use of emergency treatment and urgent care
services, reflect industry-leading practices, and for the purposes of modeling, this
benefit includes a co-payment ($100 for emergency treatment, $50 for urgent care),
unless the visit results in an admission or the co-payment represents an undue financial
burden for the Veteran. Under the New VCP, reliance on VA health care for emergency
treatment and urgent care is expected to increase, with VA becoming the payer for 75
percent of the care currently paid for primarily by Medicare, Medicaid, and commercial
insurance (moving reliance from 43 percent to 86 percent for priority groups 16 and
from 15 percent to 79 percent for priority groups 78). The estimated incremental costs
of these changes are outlined in Table 24. The proposed expansion of emergency
treatment and urgent care is independent from the System Redesign and Solutions and
corresponding increase in reliance on VA Hospital Care, Medical Services, and
Dentistry services described above. As such, this change could be executed separately
with limited impact on the delivery of the larger program.
Table 24: Estimated Incremental Costs for New VCP Emergency Treatment Changes
Phase I
Incremental
($ M)
New VCP - ER/Urgent Care Medical and
Administrative Cost

Phase II
Incremental
($ M)

Phase III: Year 1


Incremental
($ M)

2,045

2,137

(644)

(648)

1,401

1,489

New VCP - ER/Urgent Care Revenue Offset

New VCP ER/Urgent Care Total Net


Cost

Potential Offsets for Resource Requirements of the New VCP


VA understands that the costs of health care are rising, both for care delivered at the VA
and in the community. Given the rapid increase in costs, stakeholders may have to
consider changes to the VA care delivery model and system. The considerations below

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Plan to Consolidate Community Care Programs

may represent options for offsetting health care costs of community care going forward.
VA has not yet developed estimates for the magnitude of these potential savings.

Potential VA Facility OffsetDelivering more community care may lead to


underutilized resources within VA facilities. To better align resources, VA needs the
flexibility to improve management of its current infrastructure. Currently, VA has
336 buildings that are vacant or less than 50 percent occupied. This means VA
maintains more than 10.5M square feet of unneeded spacetaking funding from
needed Veteran services. VA is seeking the legislative authority to conduct a review
of existing facilities and make changes based on excess capacity. Cost savings are
likely to be significant.

Incentivizing Appropriate Health BehaviorsVA has limited tools for incentivizing


Veterans to seek care in a manner that supports positive health outcomes. Costsharing arrangements (co-payments, coinsurance, and deductibles) are one way of
encouraging these behaviors. Currently, enrolled Veterans have limited cost-sharing
arrangements for most services. In order to encourage Veterans to use higherquality, higher-value providers, revisions to these arrangements should be explored.
The impact on Veteran behavior and amount of any cost offset would vary greatly
depending on the nature and the amount of the revised cost-sharing arrangement.

Identifying Services Best Performed in the CommunityAs VAs highperforming network develops, certain services (high quality, high value) may be
identified to be the best or more efficiently provided by the community and not by
VA. Should these services shift to the community, VA may be able to repurpose
associated internal facilities for other uses. The amount of potential savings from
these changes depends on the specific services that are referred into the community
and the timelines to repurpose resources.

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Plan to Consolidate Community Care Programs

6.0

Legislative Proposal Recommendations

Legislation
The Secretary shall submit to the Committees on Veterans Affairs of the House of
Representatives and the Senate a report containingany recommendations for
legislative proposals the Secretary determines necessary to implement such plan

Introduction
To successfully implement critical reforms, VA needs additional legislative authorities to
improve access to community care, consolidate VAs community care programs,
improve emergency treatment and urgent care services, and realign current processes
to support reforms. This section provides detailed information regarding the legislative
changes needed to address current deficiencies and improve the health care services
Veterans receive. Without these additional authorities, VA will not be able to implement
the New VCP and make critical reforms.
The primary objectives of the legislative proposal recommendations are to make
immediate improvements to community care, establish the New VCP, and implement
necessary business process improvements. The legislative proposal recommendations
are divided into three sections: Immediate Improvements to the Veterans Choice
Program, Establishing a Single Program for Community Care, and Process and
Organizational Improvements.
1. Immediate Improvements to the Veterans Choice Program. The three legislative
proposal recommendations below are necessary to provide VA with the authorities
to improve access to care while beginning to consolidate community care programs.
These proposals would allow VA to work more easily with community providers and
provide VA the flexibility for community care funding. These legislative authorities
are critical to meet the needs of Veterans today and in the future. The legislative
proposal recommendations include:
Improving VAs Partnerships with Community Providers to Increase Access to
Care (Provider Agreements).
Improving Access to Community Care through Choice Fund Flexibility.
Increasing Accuracy of Funding by Recording Community Care Obligations at
Payment.
2. Establishing a Single Program for Community Care. These legislative proposal
recommendations allow VA to consolidate community care, establish a Community
Care Account, phase out unnecessary authorities and programs for community care,
and improve access to emergency treatment and urgent care. These proposals
include:
Improving Veterans Access to Community Care by Establishing the New VCP.

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Plan to Consolidate Community Care Programs

Increasing Access and Transparency by Requesting Budget Authority for a


Community Care Account.
Streamlining Community Care Funding.
Improving Veterans Experience by Consolidating Existing Programs.
Improving Veterans Access to Emergency Treatment and Urgent Care.

3. Process and Organizational Structure Improvements. The legislative proposal


recommendations below provide VA with the necessary authorities to improve care
coordination, collection of payments from OHI, and improve timely payments to
community providers.
Improving Care Coordination for Veterans through Exchange of Certain Medical
Records.
Aligning with Best Practices on Collection of Health Insurance Information.
Formalizing VAs Prompt Payment Standard to Promote Timely Payments to
Providers.
At the end of the section, Table 25 provides a description and the impact of the
legislative proposal recommendations. Additional information or legislative text will be
provided upon request.

6.1

Immediate Improvements to the Veterans Choice Program

Title: Improving VAs Partnerships with Community Providers to Increase Access


to Care (Provider Agreements)
The purpose of this proposal is to improve VAs flexibility to meet Veterans demand for
hospital care, medical services, and extended care services. This proposal would
authorize VA to purchase care in certain circumstances through agreements that are
not subject to certain provisions of law governing Federal contracts. It also would
amend 38 U.S.C. Section 1745 to permit VA to enter into agreements exempt from
certain provisions of law governing Federal contracting. Specifically, an agreement
under this section could be awarded without regard to competitive procedures and
would not subject a State Veterans Home to certain laws that are applicable to
providers and suppliers of health care services through the Medicare program.
This bill was recently introduced as Senate Bill S.2179 and VA supports its rapid
passage.
Title: Improving Access to Community Care through Choice Fund Flexibility
It is critical for VA to have flexibility to use existing Choice Funds to pay for community
care. This proposal would authorize VA to use the existing Choice Funds to pay for any
compensation and pension exams or any health care services under Chapter 17 of Title
38, including care for certain dependents, extended care services, and emergency
treatment through non-Department provider. This is the same flexibility that was

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Plan to Consolidate Community Care Programs

afforded VA by the VA Budget and Choice Improvement Act and it would facilitate VAs
efforts to consolidate and streamline the Departments non-VA care authorities. It is
critical for VA to have flexibility to use existing Choice Funds to pay for care within the
community.
Title: Increasing Accuracy of Funding by Recording Community Care Obligations
at Payment
The purpose of this proposal for appropriations act authority is to address two
inefficiencies in the obligating of funds that were found during a recent Inspector
General (IG) audit. In reality, current processes requirements in this area are
incompatible with the efficient use of resources provided to VA. During a recent IG
audit, it was determined that for FY 2013, more than $500M in Non-VA Care
deobligations had occurred in the first 18 months after the fiscal year end, foregoing
funds that could have provided more health care for Veterans. Additionally, if the
eventual expenditures exceed the obligation amount, a potential violation of the
Anti-Deficiency Act (ADA) is created, unless sufficient prior-year deobligations from
other sources are available at that time. In FY 2014, five VISNs collectively requested
an additional $110M in two-year funds that would have otherwise been available for
FY 2015 requirements because they had underestimated the obligation amount
required for FY 2014 authorizations.
Under current practice, VHA administratively and clinically approves community care
consults. Administrative approval indicates the patient is eligible for a VHA medical
benefits package and care outside the VA, if required. Clinical approval indicates the
care is medically necessary for the patients health and well-being per non-VA Care
Coordination processes. After establishing administrative and clinical approval, the
medical facilitys non-VA Care Team generates an authorization for care. An
authorization gives a community provider authority to provide health care to the Veteran
patient and provides assurance of payment for those services. The authorization
document binds VA to the language that is included on the authorization.
VAs legal liability to pay for community care occurs when the authorization for care is
generated. In accordance with the Recording Statute, 31 U.S.C. Section 1501 and the
ADA, 31 U.S.C. Section 1341(a)(1), VA records an obligation covering the estimated
amount of the non-VA care. These amounts are highly unpredictable and this
unpredictability has led to significant deobligations after the end of the fiscal year,
resulting in large balances of expired prior-year appropriations in the Medical Services
account. The unpredictable nature of the health care needed also adds significant risk
of ADA violations because of under-estimated obligations.
In compliance with the Recording Statute and to protect against potential violations of
the ADA, VA must record obligations when authorizations are issued. Each
authorization may ultimately be used once, several times, or not at all by the Veteran

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who receives it, but VA must record an obligation amount at the time the authorization is
issued that is sufficient to cover the ultimate expenditures from that authorization.
Expenditures can lag several months to several years after the care has been
authorized, and amounts frequently vary from the original estimated obligations. If the
Veteran does not use an authorization, there are no resulting expenditures.
The penalty for over-obligation is a prior-year de obligation, foregoing funds provided by
Congress with no other penalty. Conversely, the penalty for under-obligation is a
potential ADA violation, with a published report to the President, Congress and the
Government Accountability Office identifying the responsible officials, potential
detrimental administrative action against those officials, and potential criminal penalties
if the violation is determined to have been knowing and willful. Because of the
difference in possible penalties, there is a strong incentive to over-obligate to preclude a
potential ADA violation.
This proposed appropriations act legislation would allow VA to record the obligation
when the amount is certain (i.e., when VA approves the payment of the claim for the
incident of care) without regard to the requirements of the Recording Statute and ADA.
It would likely reduce the potential for large deobligation amounts after the funds have
expired. VA already records obligations for CHAMPVA and Millennium Bill emergency
treatment claims, for which authorizations are not generated, upon payment of the
claim.
This proposed legislation will greatly reduce, and probably eliminate, any potential for
ADA violations, as well as the potential for large deobligation amounts after the funds
have expired. VA already uses this process for CHAMPVA and Millennium Bill
emergency treatment claims, which require no authorizations, without incident. Per
discussion with the DoD Health Affairs TRICARE staff, who have similar authority to that
proposed for VA, there have been no ADA violations resulting from this authority.

6.2

Establishing a Single Program for Community Care

Title: Improving Veterans Access to Community Care by Establishing the New


VCP
The purpose of this legislative proposal is to establish the New VCP that would
consolidate all community care programs and improve Veterans access to community
care. This proposal would amend Chapter 17 of Title 38, U.S.C. to add a new section
establishing the New VCP. This provision would authorize the Secretary to furnish
Hospital Care and Medical Services to eligible Veterans through agreements with
certain eligible entities. Veterans would be eligible for Hospital Care and Medical
Services through the New VCP based on the wait-time for the needed care at VA, the
availability of the service from VA, the geographic distance a Veteran must travel, or the
convenience of the Veteran.

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VA relies heavily on long-term relationships with specific Federal and academic


partners. Many of these relationships were disrupted due to new and cumbersome
processes established in The Choice Act to become Choice providers. VA believes
altering the new programs authorization from The Choice Act could remedy these
problems. To preserve and build on existing relationships, certain non-Department
providers, such as DoD, IHS, THP, FQHC, and select academic departments that have
an affiliation agreement with VA would be considered part of VAs core provider
network.
Under the proposal, a Veteran eligible for care under the New VCP program could elect
to receive necessary Hospital Care and Medical Services from an eligible entity that has
an agreement to provide such care and services for VA. Veterans will be responsible
for paying the applicable co-payments required by statute and established in regulation
to VA. The term agreement would be defined to include contracts and provider
agreements.
VA would be responsible for payment for the care and services furnished under this
program. VA would use existing authority to make third-party collections from a
Veteran's OHI for care provided for a non-service connected condition. Under the New
VCP, VA would like to evolve to value-based payment models instead of using fee for
service schedules. This will require additional flexibility as pilot payment models
mature. To better align resources, VA will need to be able to better manage its current
infrastructure by closing locations that are not economically sustainable and old,
outdated buildings.
Title: Increasing Access and Transparency by Requesting Budget Authority for a
Community Care Account
To increase visibility and accountability within the community care program, VA will
request budget authority for a new Community Care Account. By requesting separate
appropriations for an account solely funding community care, VA will have a more
central and coherent fiscal structure for administering this program. This will improve
VAs ability to meet Veterans needs. Section 4003 of the VA Budget and Choice
Improvement Act requires that VA include an appropriations account for
non-Department provider programs as part of its annual budget request.
In future budget requests, we will request that Congress appropriate budget authority to
this account in the annual appropriations act. The account, which will be known as the
Community Care account, will be the sole source of funding for care that VA provides
to Veterans through community providers. Separating the funding of Veteran
community care from the current VA hospital care and medical service funding will
require local leaders to set a clear funding level and actively manage community care.
VA will also request the appropriations act authority to transfer funds among the

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Veterans Community Care, Medical Services, and Medical Support and Compliance
accounts and the authority to deposit Medical Care Collection Funds receipts into the
Community Care Account.
Title: Streamlining Community Care Funding
This legislative proposal would increase both accountability and visibility on community
care resources and expenditures at local facilities and at higher levels by amending
Section 106(b) of PL 113-146. This provision actually has had the effect of impeding
VA from putting in place an efficient process for funding community care. Under these
requirements, there is no direct link between the resources and the purchased care
demand at the local VA Medical Center level.
We propose Section 106(b) be amended to adapt the current model used for funding
VAs Consolidated Mail-Out Pharmacies (CMOPs), where VA Medical Centers estimate
their total requirement for the year, provide the funds to their supporting CMOP, and
adjust funding levels up or down for variances in demand during the year. Variances
may occur for reasons unknown at the time the budget is submitted, such as the
retirement of a specialty physician that causes demand for purchased care to increase
until a replacement is hired. Conversely, funds that were intended for purchased care
at the beginning of a fiscal year could be realigned to pay for staff at the local VA
Medical Center if successful hiring of scarce medical providers offers an opportunity to
deliver the required care in-house rather than through purchased care.
Title: Improving Veterans Experience by Consolidating Existing Programs
Consolidating and streamlining community care is a central goal of the plan required by
PL 114-41. To meet this requirement, certain existing authorities and programs will
need to sunset. Some of these authorities are described below:
If the New VCP outlined above were enacted, 38 U.S.C. Section 1703, which authorizes
VA to contract for Hospital Care and Medical Services for certain Veterans, would be
superfluous. Section 1703 should be amended to add a sunset or expiration date of
December 31, 2017.
The authority to contract for scarce medical resources, 38 U.S.C. Section 7409, is no
longer utilized. VA currently relies on 38 U.S.C. Section 8153 to contract for these
medical resources. Section 7409 should be repealed.
Project ARCH, Section 403 of PL 110-387 (as amended), was designed to improve
access for eligible Veterans by connecting them to health care services closer to home.
The New VCP will address these same access issues. Project ARCH will sunset in
August 2016 and VA will develop a plan to address continuity of care for affected
Veterans.

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The Assisted Living for Veterans with TBI (AL-TBI) pilot program authorized by
Section 1705 of PL 110-181(as amended) provides assisted living services to certain
eligible Veterans with TBI. The pilot program is currently scheduled to sunset in
October 2017. VA does not provide assisted living services to any other group of
Veterans. This pilot program should not be extended if a true consolidation of
community care is to take place. This pilot of assisted living services is inconsistent
with the scope of the medical benefits that VA provides in all other health programs. As
required by statute, VA is providing quarterly reports to Congress on, among other
things, VAs interim findings and conclusions with respect to the success of the pilot
program. VAs future reports to Congress on the pilot program will make
recommendations for the future direction of care for the Veteran cohort eligible for this
pilot program.
Title: Improving Veterans Access to Emergency Treatment and Urgent Care
The purpose of this legislative proposal is to address VAs existing authorities to
reimburse the cost of emergency treatment. In addition, this proposal would clarify
reimbursement for emergency transportation services. Veterans often seek emergency
treatment with a misunderstanding of VAs authority to pay for their treatment and are
surprised when VA is unable to cover their bills. The complexities of the current law
also creates confusion for those who administer the program. VAs plan envisions an
expanded authority to reimburse costs associated with emergency treatment for
enrolled Veterans, who are active VA health care participants, in a more consistent and
understandable way.
We propose to amend 38 U.S.C. Section 1725 to authorize VA to reimburse the
reasonable costs of emergency treatment and emergency transportation provided to
eligible Veterans. VA would utilize a definition of emergency treatment similar to the
definition specified in current 38 U.S.C. Section 1725(f). Eligible Veterans would be
those who are enrolled and are active health care participants in VA. An active health
care participant is a Veteran who has sought care from VA within the last 24 months.
VA would be the primary payer for the treatment provided under this section. The
provision would authorize VA to set the maximum amount payable under this provision
and specify that VA payment is payment in full. Consolidating VAs emergency
treatment authorities into a single provision and providing a consistent benefit to all
eligible Veterans also would require 38 U.S.C. Section 1728 to be repealed.
In addition, the proposal would authorize VA to pay the reasonable costs of urgent care
provided to an eligible Veteran through an entity under contract or other agreement with
VA. The term urgent care would be defined by the Secretary in regulation. Eligible
Veterans would be those who are enrolled and are active health care participants in VA.
VA would be the primary payer for urgent care provided under this section.

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As VA improves access to emergency treatment, VA proposes to implement policies to


encourage more appropriate use of emergency treatment versus other points of care
provided by VA. Therefore, this proposal would require the Secretary to establish a cost
share for emergency treatment. The cost share would apply to all Veterans, unless they
meet a hardship exemption or are admitted to a hospital for treatment or observation
following the emergency treatment.
Similarly, the proposal would require the Secretary to establish a cost share for urgent
care. The cost share would apply to all Veterans, unless they are admitted to hospital
for treatment or observation or if it represents a financial obstacle to the Veteran
receiving required care.

6.3

Process and Organizational Structure Improvements

Title: Improving Care Coordination for Veterans through Exchange of Certain


Medical Records
The purpose of this legislative proposal is to improve VAs ability to share health
information for care coordination with community providers. This proposal would amend
38 U.S.C. Section 7332(b)(2) to include a provision for the disclosure of VA records of
the identity, diagnosis, prognosis, or treatment of a patient relating to drug abuse,
alcoholism or alcohol abuse, or infection with the Human Immunodeficiency Virus (HIV)
or sickle cell anemia to a health care provider in order to treat or provide care to a
shared patient. This change would not amend or create a new exception to the Health
Insurance Portability and Accountability Act (HIPAA). The proposal instead is to
address an obsolete provision of law, only applicable to VA that hinders coordination of
care.
Currently, 38 U.S.C. Section 7332(b)(2) prevents VHA from providing or sharing patient
information relating to drug abuse, alcoholism or alcohol abuse, or infection with HIV or
sickle cell anemia with public or private health care providers, including with IHS health
care providers, providing care to the shared patient under normal treatment situations
without the prior signed, written consent of the patient. This restriction poses potential
barriers to the coordination and quality of care provided to our patients by public or
private health care providers and actual barriers to providing health information to IHS
for the treatment of shared patient populations. Furthermore, this restriction is
inconsistent with other health care practices and other Federal standards related to
patient privacy.
Title: Aligning With Best Practices on Collection of Health Insurance Information
The purpose of this proposal is to improve VAs ability to collect information on OHI from
Veterans. Currently, other Federal partners, as well as private providers, require
beneficiaries to provide information on OHI. This proposal would amend Title 38,
U.S.C. by adding a new section to require an applicant for or recipient of VA medical

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care and services to provide their health plan contract information to VA. Specifically,
an applicant or recipient of VA medical care or services would be required to provide
information regarding their health plan coverage to include the name of the health plan
contract(s), the name of the policy holder if coverage is under a health plan contract
other than the name of the applicant or recipient, the plan number, and the plans group
code.
The proposal would further authorize the Secretary to define and take appropriate
action when an individual who fails to provide this information. The Secretary also
would be authorized to reconsider the application for or reinstate the provision of care or
services once the information requested has been provided. To be clear, the proposal
would not be construed as authority to deny medical care and treatment to an individual
in a medical emergency. If a medical emergency exists, VA will not deny emergency
treatment or services should the applicant or recipient fail to provide health plan contract
information.
Title: Formalizing VAs Prompt Payment Standard to Promote Timely Payments to
Providers
The purpose of this legislative proposal is to formalize VAs Prompt Pay standard to be
in alignment with the current industry guidelines established by States. This proposal
would establish a section under Title 38 for the Prompt Payment of all care provided in
the community. The legislative proposal should establish what constitutes a clean
claim that will start the payment clock. Generally, a clean claim is defined by States
as a claim that has all the information a payer needs to either pay or deny the claim. A
non-clean claim is a claim that requires additional information or documentation from
the provider. Moreover, there are States that use different time frames for paper clean
claims (usually 45 days) versus electronic clean claims (usually 30 days). In counting
the days, states vary from working/business days to calendar days for processing of
claims. VAs proposal will use the above as a guide.

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6.4

Summary of Legislative Proposals

Table 25: Summary of Legislative Proposals


Title/Topic

Description

Impact/Justification

Improving VAs Partnerships with


Community Providers to Increase
Access to Care

Amends 38 U.S.C.
Section 1745

This would allow VA to enter into agreements


exempt from certain provisions of contracting
law.

Improving Access to Community


Care through Choice Fund
Flexibility

Authorize VA to use
Veterans Choice Fund to
pay for non-Department
Care

This would provide VA with increased flexibility


to use Veterans Choice Fund to pay for health
services that Veterans receive within the
community.

Increasing Accuracy of Funding by


Recording Community Care
Obligations at Payment

Appropriations act
provision to allow VA to
record obligations for
Community Care on the
date on which payment of
a claim to a provider is
approved without regard
to the recording statute or
ADA requirements

This would allow VA to record obligations of


community care at the time of claim
adjudication.

Improving Veterans Access to


Community Care by Establishing
the New VCP

Amends Chapter 17, Title


38 to establish the New
VCP

This would establish a permanent, consolidated


non-Department Care program, the New VCP.
The New VCP would provide VA with flexibility
to meet the evolving needs of Veterans.

Increasing Access and


Transparency by Requesting
Budget Authority for a Community
Care Account

Appropriations act to
provide budget authority
in the new the
Community Care Account

The separate Community Care Account will


increase accountability and visibility of funding
for community care.

Streamlining Community Care


Funding

Amends Section 106(b)


of PL 113-146

This would improve the process for funding


community care by allowing VA the flexibility to
increase funds based on demand.

Improving Veterans Experience by


Consolidating Existing Programs

Amends Title 38 to repeal


and sunsets certain
programs

This would repeal certain authorities to contract


for care that are no longer necessary. This
would also sunset certain pilot programs,
including Project ARCH, which would be
replaced by the New VCP.

Improving Veterans Access to


Emergency Treatment and Urgent
Care

Amends 38 U.S.C.
Section 1725

This would improve emergency treatment


services and provide reimbursement for urgent
care. This provision also would authorize VA to
establish a co-pay for emergency treatment
and urgent care services.

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Plan to Consolidate Community Care Programs

Title/Topic

Description

Impact/Justification

Improving Care Coordination for


Veterans through Exchange of
Certain Medical Records

Amends 38 U.S.C.
Section 7332 (b)(2)

This would allow VA to share certain medical


records it cannot share easily today by virtue of
a special legal restriction unique to VA. This
change would be fully consistent with HIPAA.

Aligning With Best Practices on


Collection of Health Insurance
Information

Amends Title 38 to
require individuals to
provide health care
insurance information

This would add a new section to Title 38 that


would require Veterans to provide VA with OHI
information.

Formalizing VAs Prompt Payment


Standard to Promote Timely
Payments to Providers

Amends Title 38

This would clarify VAs Prompt Pay for medical


claims by applying current industry standards.

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Plan to Consolidate Community Care Programs

7.0

Descriptions of Each Non-Department Provider Program and


Statutory Authority

Legislation
The Secretary shall submit to the Committees on Veterans Affairs of the House of
Representatives and the Senate a report containing a description of each
non-Department provider program and the statutory authority for each such program
Description of each non-Department provider program and statutory authority
As more Veterans seek services through VA facilities, VA has had to increasingly
depend on non-Department providers to meet the evolving needs of Veterans.
Throughout the decades, Congress provided VA with several statutory authorities and
established numerous programs that allow Veterans to seek community care.
Additionally, VA has authority to provide some care and services to certain survivors
and/or dependents. These numerous authorities and non-VA care programs are
cumbersome and oftentimes confusing for Veterans, community providers, and VA staff
to understand and administer.
The five tables below detail VAs authorities to provide community care. These include
VAs contracting authorities (Table 26), reimbursement authorities (Table 27),
community care programs (Table 28), benefits programs (Table 29), and authorities to
contract for specific health care services (Table 30). Each table provides information
regarding the statutory authority, nature of the provision, description, eligibility criteria,
and beneficiary.
Table 26 provides details on three statutes that authorize VA to enter into contracts with
community providers for health care services. Note: Authorities to contract for specific
types of care are detailed in Table 30 below.
Table 26: VAs General Contracting Authorities for Health Care
Title and Statutory
Authorities
Contracts for
Hospital Care and
Medical Services in
Non-Department
facilities

38 U.S.C. Section
1703

Nature of
Provision
Contracting

Description

Eligibility Criteria

Beneficiary

Authority to contract
for Hospital Care
and Medical
Services when VA
facilities are not
capable of
furnishing
economical care
due to geographic
inaccessibility or are
not capable of
furnishing care; can

Criteria specified in
statute and
regulations.
Authority to contract
for care based on
type of care needed
and whether or not
the Veteran is SC.

Certain Veterans as
specified in statute

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Plan to Consolidate Community Care Programs

Title and Statutory


Authorities

Nature of
Provision

Description

Eligibility Criteria

Beneficiary

also furnish
counseling and
related Mental
Health services
under 38 U.S.C.
Section
1712A(e)(1).
Sharing of Health
Care Resources

Sharing authority;
Contracting

Broad authority to
make
arrangements, by
contract or other
forms of agreement,
for the mutual use,
or exchange of use,
of health care
resources between
VA facilities and any
health care
provider, or other
entity or individual.
Sharing agreements
with affiliates are
executed under this
authority.

VA can use the


authority to provide
care to any
individual VA is
authorized to treat
(or reimburse for
treating).

Veterans or
individuals
authorized to
receive care under
Title 38

Sharing authority

Authority to enter
into sharing
agreements and
contracts with DoD
for the mutual use
or exchange of use
of hospital and
domiciliary facilities,
and such supplies,
equipment, material,
and other resources
as may be needed.

N/A

Veterans Service
members

38 U.S.C. Section
8153

Sharing of VA and
DoD health care
resources

38 U.S.C. Section
8111

Table 27 provides details on the statutes that are cited when VA reimburses community
providers for health care services. These reimbursement authorities are related to
emergency treatment and care provided in IHS/THP facilities.

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Plan to Consolidate Community Care Programs

Table 27: VAs Authority to Reimburse for Community Care


Title and Statutory
Authorities
Reimbursement for
Emergency
Treatment

Nature of
Provision

Description

Eligibility Criteria

Reimbursement

Authority to
reimburse the
reasonable value of
emergency
treatment furnished
in a non-VA facility.

Veteran must be an
active health care
participant and
personally liable for
the emergency
treatment (terms are
defined in the law).

Certain Veterans

Reimbursement

Authority to
reimburse the U&C
charges of
emergency
treatment furnished
in a non-VA facility
where such
treatment was
needed for/related
to a SC condition or
in certain instances
vocational rehab (38
U.S.C. Chapter 31),
or provided to a
Veteran
permanently and
totally disabled.

Veteran must be
eligible for VA
health care and
treatment must be
rendered for
conditions specified
in statute.

SC Veterans

Reimbursement

Authorizes the
Secretary of HHS to
enter into or expand
sharing
arrangements
between IHS, tribes,
and Tribal
Organizations, and
VA and DoD. This
authority is cited in
VAs Direct Care
Services
reimbursement
agreements with
IHS and THP.

In general,
agreements apply to
American Indians
and Alaska Native
(AI/AN) Veterans,
eligible for services
from VA and IHS or
the THP. NonAI/AN Veterans may
also be eligible
under agreements
with Alaska THP.

Certain Veterans

38 U.S.C. Section
1725
Reimbursement of
certain medical
expenses
(emergency
treatment)

38 U.S.C. Section
1728

Sharing agreements
with Federal
agencies (IHS/THP
Reimbursement
Agreements)

25 U.S.C. Section
1645

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Plan to Consolidate Community Care Programs

Table 28 provides details on the three community care programs that allow Veterans to
access community providers for health care services. 60
Table 28: VAs Community Care Programs
Title and
Statutory
Authorities
Veterans
Choice
Program

Nature of
Provision

Description

Eligibility Criteria

Beneficiary

Contracting
and Provider
Agreement

Temporary program to furnish


Hospital Care and Medical
Services to eligible Veterans
through eligible non-VA
providers.

Certain Veterans, generally


based on residence or
wait-time criteria. Criteria
are specified in statute and
regulations.

Certain
Veterans

Pilot
implemented
via contract

Pilot program in five VISNs to


provide by contract covered
health care services to covered
Veterans. Pilot set to expire in
August 2016.

Specific criteria set forth in


statute, including
enrollment, for a VA facility
providing primary and
tertiary care.

Certain
Veterans
based on
driving times
to certain
services

Pilot
implemented
via contract

Pilot program to assess the


effectiveness of providing
community-based brain injury
residential rehabilitative care
services to eligible Veterans with
TBI to enhance their
rehabilitation, quality of life, and
community integration.

Specific criteria set forth in


statute, including enrollment
in VA health care and
receipt of VA care for
moderate-to-severe TBI.

Certain
Veterans

PL 113-146
Section 101
(as amended)

Project
ARCH

PL 110-387
Section 403
(as amended)

AL-TBI Pilot
Program

PL 110-181,
Section 1705
(as amended)

Pilot expires on October 6, 2017.

60

This table does not include VA Dental Insurance Pilot (PL 111-163 510).

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Plan to Consolidate Community Care Programs

Table 29 provides details on six benefit programs through which VA provides health care
to eligible Veterans, survivors, dependents, family members, and caregivers through
community providers.
Table 29: VAs Benefit Programs to Provide Services to Veterans, Survivors, and
Dependents
Title and
Statutory
Authorities
FMP

Nature of
Provision

Description

Eligibility Criteria

Benefit

Authority to provide
Hospital Care and
Medical Services
outside a state if such
services are needed for
treatment of a SC
disability or as part of a
rehabilitation plan under
38 U.S.C. Chapter 31.

SC Veterans treated
for SC conditions.

Veterans

Benefit

Provides medical care


for eligible survivors,
dependents, and
caregivers of certain
Veterans.

Specific criteria set


forth in statute.
Cannot be eligible for
TRICARE.

Certain Survivors,
Dependents, and
Caregivers

Benefit
(Reimbursement)

Provides
reimbursement to family
members of
certain Veterans for
care associated with
specific medical
conditions.

Specific criteria, such


as length of time a
person resided at
Camp Lejeune, set
forth in statute and
regulations.

Certain family
members

Benefit

Authority to provide
children of Vietnam
Veterans and Veterans
of covered service in
Korea suffering from
spina bifida with health
care. What constitutes
health care is defined in
statute.

Specific criteria, such


as definitions of child
and covered defect,
set forth in statute
and regulations.

Certain children of
certain Veterans

38 U.S.C.
Section 1724

CHAMPVA

38 U.S.C.
Section 1781

Camp
Lejeune
Family
Member

Beneficiary

38 U.S.C.
Section 1787

Spina Bifida

38 U.S.C.
Section 1803;
38 U.S.C.
Section 1821

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Plan to Consolidate Community Care Programs

Title and
Statutory
Authorities
CWVV

Nature of
Provision

Eligibility Criteria

Beneficiary

Benefit

Authority to provide
eligible CWVV with
needed care for that
childs covered birth
defects or any disability
associated with those
birth defects.

N/A

Certain children of
certain Veterans

Benefit

Authority to provide
care to a newborn child
of a woman Veteran
receiving maternity care
from VA for not more
than seven days after
the birth of the child if
the child is delivered in
a VA facility or another
facility pursuant to a
contract.

N/A

Newborn children of
certain Veterans

38 U.S.C.
Section 1813

Care for
Newborn
Children of
Women
Veterans
Receiving
Maternity
Care

Description

38 U.S.C.
Section 1786

Table 30 provides details on 15 statutes that authorize VA to furnish specific care and
services through community providers.
Table 30: VAs Authority to Furnish Specific Services by Community Providers
Title and
Statutory
Authorities
Contract
Nursing Home
Care

Nature of
Provision

Description

Eligibility Criteria

Contract

Authority to contract with


certain providers for nursing
home care, adult day health
care, or other extended
care services. Care is
limited to six months,
unless certain exceptions
are met.

Specific criteria set


forth in statute and
regulations.

Veterans who have been


furnished care by the
Secretary in a facility
under the direct
jurisdiction of the
Secretary and require a
protracted period of
nursing home care.

Contract

Authority to contract or
enter into an agreement
with each State home for
payment of nursing home
care.

Certain SC
Veterans

Veterans in need of care


for a SC condition or
Veterans who are
70 percent or more SC
and in need of nursing
home care.

38 U.S.C.
Section 1720
State Veterans
Homes (Nursing
Home Care)

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Beneficiary

Plan to Consolidate Community Care Programs

Title and
Statutory
Authorities

Nature of
Provision

Description

Eligibility Criteria

Beneficiary

38 U.S.C.
Section 1745

Non-institutional
alternatives to
nursing home
care

Contract

VA may furnish care in


non-institutional settings for
eligible Veterans and VA
shall furnish appropriate
health-related services
solely through contracts.

N/A

Certain Veterans

Contract

VA may furnish respite care


services to enrolled
Veterans and may enter
into contracts for
this purpose.

N/A

Veterans

Contract

Discretionary authority, not


implemented by VA, to
contract with appropriate
entities to provide
specialized residential care
and rehabilitation services
to eligible OEF/OIF/OND
Veterans who suffer from a
TBI and meet other
statutory criteria.

N/A

Certain Veterans

Contract

Discretionary authority, not


implemented by VA that
authorizes VA, in
implementing and carrying
out rehabilitation and
reintegration plans

N/A

N/A

38 U.S.C.
Section 1720C
Respite Care

38 U.S.C.
Section 1720B
Specialized
Residential Care
and
Rehabilitation
Services to
Eligible
Operation
Enduring
Freedom
(OEF)/Operation
Iraqi Freedom
(OIF)/Operation
New Dawn
(OND) Veterans

38 U.S.C.
Section 1720(g)
Not
implemented by
VA
TBI: Use of
non-Department
facilities for
rehabilitation

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Plan to Consolidate Community Care Programs

Title and
Statutory
Authorities

Nature of
Provision

Eligibility Criteria

Beneficiary

developed under 38 U.S.C.


Section 1710C, to provide
Hospital Care and Medical
Services, including
rehabilitative services, for
eligible Veterans and
Service members with TBI
through cooperative
agreements with
appropriate entities that
have established long-term
neurobehavioral
rehabilitation and recovery
programs.

38 U.S.C.
Section 1710E

Not
implemented by
VA

Appropriate
Care for
Gender-Specific
Disabilities of
Women
Veterans

Description

Contract

Each VA health care facility


must be able to provide,
directly or by contract under
38 U.S.C. Sections 7409,
8111, or 8153, as
appropriate, timely care for
any gender-specific
disability of an eligible
woman Veteran.

N/A

Women Veterans

Contract

VA shall provide counseling


and services to Veterans
with MST and may furnish
counseling pursuant to a
contract.

N/A

Veterans

Contract

VA may contract (when VA


resources are not available)
with community Mental
Health centers and other
qualified entities to furnish
peer outreach, peer
support, readjustment
counseling, and Mental
Health services to Veterans
and family members for
three years post
deployment.

N/A

Certain Veterans and


family members

PL 98-160, as
amended by PL
102-40 and PL
102-83
Counseling and
treatment for
Military Sexual
Trauma (MST)
38 U.S.C.
Section 1720D
Readjustment
and Mental
Health Services
for OEF/OIF
Veterans

PL 111-163
304, as
amended by PL
112-239

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Plan to Consolidate Community Care Programs

Title and
Statutory
Authorities
Substance Use
Disorder
Treatment

Nature of
Provision

Description

Eligibility Criteria

Beneficiary

Contract

Permits VA through
contract or fee-for-service
payments to provide a
range of services for
substance use disorder
treatment.

N/A

N/A

Contract

In consultation with Papa


Ola Lokahi and other
organizations to enter into
contracts or agreements
with Native Hawaiian health
care systems for
reimbursement of direct
care services for Native
Hawaiians.

N/A

Certain Veterans

Contract

Authority to enter into


contracts with institutions
and persons to provide
scarce medical specialist
services at VA facilities.

N/A

N/A

Contract

Authority to contract for


care, treatment, and
rehabilitative services for
certain Veterans.

Veterans suffering
from serious
mental illness and
homeless
Veterans

Veteran must be enrolled


(or eligible to enroll) in VA
health care

Contract
and other

Authority to procure
prosthetic appliances and
services by purchase,
manufacture, contract, or
any other manner.

N/A

N/A

PL 110-387
103
Native Hawaiian
Health Care
Systems

PL 113-146
103

Contract for
Scarce medical
specialist
services
38 U.S.C.
Section 7409
Health Care for
Homeless
Veterans
38 U.S.C.
Section 2031

Procurement of
Prosthetic
Appliances
38 U.S.C.
Section 8123

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Plan to Consolidate Community Care Programs

Title and
Statutory
Authorities

Nature of
Provision

Care and
Contract
treatment of U.S. and grant
Veterans by the
Veterans
Memorial Medical
Center
(Philippines)

Description

VA is no longer contracting
with the Veterans Memorial
Medical Center; however,
VA does provide grants for
medical equipment.

38 U.S.C.
Section 1732

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Eligibility Criteria

N/A

Beneficiary

N/A

Plan to Consolidate Community Care Programs

8.0
8.1

Appendix
Glossary61

Administrative Information: Information supporting the business functions of VA and


external providers, including authorizations, medical claims, VA formularies, and referral
documentation.
Application-Programming Interface (API): A language used by one computer system
to communicate and link to another computer system.
Authorization: A decision that a health care service, treatment plan, prescription drug,
or DME is medically necessary and will be paid.
Claim: Itemized statement of services and costs from health providers submitted to
insurer.
Clinical Information: Patient medical information found in medical records, including
medical histories, physical findings, test results, and treatments.
Credentialing: A formal review of the qualifications of a health care provider who has
applied to participate in a health care system or plan.
Critical Pathway: An outline or diagram that documents the process of diagnosis or
treatment deemed appropriate for a condition based on practice guidelines.
EDI: Computer-to-computer exchange of information.
External Network: A network of commercial community providers not in the core
network divided into Standard and Preferred tiers.
Formulary: A list of preferred pharmaceuticals to be used by a managed care plans
network physicians, chosen based on the drugs' efficacy, safety, and cost effectiveness.
Health Information Management: Collection and analysis of health care data to
provide information for health care decisions involving patient care, institutional
management, health care policies and planning, and research; formerly known as
medical records management.
Network Manager: VA will conduct a make/buy analysis to determine who will manage
the external network. As a result, either VA or a commercial network manager may
manage the network.

61Definitions

in glossary are drawn from VA internal sources, medical dictionaries, and institutions
containing industry standard definitions. These include CMS, The Farlex Medical Dictionary for Health
Professions and Nursing, and the McGraw-Hill Concise Dictionary of Modern Medicine.

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Plan to Consolidate Community Care Programs

Preferred Tier: VA community providers that meet minimum credentialing


requirements, in addition to performing highly against quality metrics, demonstrating
high-value care, and signing a pledge to serve U.S. Veterans. VA will explore bonuses
and incentives for providers in the Preferred tier.
Referral: A written or electronic transfer of care initiated by a clinician that enables a
patient to see another provider for specific care or to receive medical services.
Referral Coordinator: A care support role that helps Veterans understand related
processes and facilitates administrative care functions.
Retail Pharmacy Network: A network of community pharmacies capable of providing
prescription fulfillment services, medication counseling, and other authorized services,
following specific business rules established by VA.
Standard Tier: VA community providers that meet minimum credentialing
requirements and do not fall into the VA Core Network.
VA Core Network: A network of high-quality providers in DoD, IHS, THP, FQHC, and
academic teaching affiliates.
VA Health Information Gateway and Services (Future State): Online application(s)
for health care providers and potentially patients to interact with patient clinical and
administrative information, which is integrated with VA information systems.
VistA: Health information system that provides an integrated inpatient and outpatient
EHR for VA patients and administrative tools to help VA deliver the best quality medical
care to Veterans.

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8.2

Acronym List

Accountable Care Organizations (ACOs)


Activities of Daily Living (ADL)
Anti-Deficiency Act (ADA)
Agency for Healthcare Research and Quality (AHRQ)
American Indians and Alaska Native (AI/AN)
Assisted Living for Veterans with TBI (AL-TBI)
Centers for Medicare and Medicaid Services (CMS)
Children of Women Vietnam Veterans (CWVV)
Civilian Health and Medical Program of the VA (CHAMPVA)
Computerized Patient Record System (CPRS)
Consolidated Mail-Out Pharmacies (CMOPs)
Department of Defense (DoD)
Deputy Under Secretary for Health (DUSH)
Durable medical equipment (DME)
Electronic data interchange (EDI)
Electronic health records (EHR)
Enterprise Health Management Platform (eHMP)
Federally Qualified Health Centers (FQHC)
Fiscal Year (FY)
Foreign Medical Program (FMP)
Health and Human Services (HHS)
Health Information Exchanges (HIEs)
Health Insurance Portability and Accountability Act (HIPAA)
Health Resources and Services Administration (HRSA)
Human Immunodeficiency Virus (HIV)
Indian Health Service (IHS)
Information technology (IT)
Inspector General (IG)
Joint Legacy Viewer (JLV)
Military Sexual Trauma (MST)
National Committee for Quality Assurance (NCQA)
New Veterans Choice Program (New VCP)
Office of Management and Budget (OMB)
Office of the National Coordinator for Health Information Technology (ONC)
Operation Enduring Freedom (OEF)
Operation Iraqi Freedom (OIF)
Operation New Dawn (OND)
Other health insurance (OHI)
Patient-Aligned Care Team (PACT)
Patient-Centered Community Care (PC3)
Primary care providers (PCPs)

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Plan to Consolidate Community Care Programs

Project Access Received Closer to Home (ARCH)


Prompt Payment Act (PPA)
Public Law (PL)
Request for Proposals (RFPs)
Service-connected (SC)
Telemedicine Intensive Care Unit (TeleICU)
The Department of Veterans Affairs (VA)
Third-party administrators (TPAs)
Tribal Health Programs (THP)
Usual and customary (U&C)
U.S. Code (U.S.C.)
Veterans Access, Choice, and Accountability Act of 2014 (The Choice Act)
Veterans Health Administration (VHA)
Veterans Health Information Systems and Technology Architecture (VistA)
Veterans Integrated Service Network (VISN)
Veterans Service Organizations (VSOs)

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Plan to Consolidate Programs of Department of Veterans Affairs to Improve Access to Care

8.3

Alignment with Independent Assessment Recommendations

Table 31: Alignment with Independent Assessment Report Recommendations


Independent Assessment
Recommendation

Description of Alignment to New VCP

Recommendation 1 GOVERNANCE: Align demand, resources, and authorities.


Clarify and simplify the rules for
purchased care to provide the best
value for patients

The plan will consolidate existing authorities and mechanisms for delivering community
care into a single program, the New VCP, simplifying the process for Veterans,
providers, and VA staff (Element 1: Single Program for non-Department Care Delivery
and Element 2: Patient Eligibility Requirements).

Recommendation 2 OPERATIONS: Develop a patient-centered operations model that balances local autonomy with appropriate
standardization and employs best practices for high-quality health care

Fix substandard processes that impede


the quality of care provided to the
Veteran

The New VCP proposes revised processes for Authorizations (Element 3), Claims
Management (Element 5), and Medical Records Management (Chapter 9).
Care coordination should improve health outcomes, prevent gaps caused by transition of
setting or time, and support a positive and engaging patient experience (Introduction:
Care Coordination).

Recommendation 3 DATA and TOOLS: Develop and deploy a standardized and common set of data and tools for transparency,
learning, and evidence-based decision.
Implement a single, integrated set of
system-wide tools centered on a
common EHR that is interoperable
across VHA and with DoD and
community provider systems.

The New VCP proposes medical records management to increase electronic transfer of
relevant medical records between VA, Core Network, including DoD, and community
providers, improving the consistency, simplicity, and timeliness of the information
exchange (Element 9: Medical Records Management).

The New VCP proposes approaches for High-Performing Network Development,


including analytics, that are adaptable over time and can adjust to meet the needs of a
changing Veteran population, providing them with access to a tiered network (Element 8:
Plans to Use Current Non-Department Provider Networks and Infrastructure).
The New VCP will develop a high-performing network nimble enough to adjust to shifts
in the geographic distribution of Veterans (Chapter 6: Plan to Develop Provider Eligibility
Requirements and Element 8: Plans to Use Current Non-Department Provider Networks
and Infrastructure).
The authorization, medical records management, and claims processes outlined in the
New VCP support increased transparency of data on health care utilization in the
community (Element 3: Authorizations, Element 5: Provider Reimbursement Rate, and
Element 9: Medical Records Management).
Data analytics will be used to improve health care outcomes and personalize care
delivery.

Assessment A. Demographics

Prepare for a changing Veteran


landscape
Anticipate potential shifts in the
geographic distribution of Veterans,
and align VA facilities and services to
meet these needs

Improve collection of data on Veteran


health care utilization and reliance

Assessment B. Health Care Capabilities


Consider alternative standards of timely
access to care.

Shifting to a single community care program will give VA greater flexibility in identifying
and responding to access issues (Element 1: Single Program for non-Department Care
Delivery).

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Plan to Consolidate Community Care Programs

Independent Assessment
Recommendation

Description of Alignment to New VCP

Develop and implement more sensitive


standards of geographic access to
care.
Take significant steps to improve
access to VA care
Streamline programs for providing
access to purchased care and use
them strategically to maximize access.

Systematically study opportunities to


improve access to high-quality care
through use of purchased care.

Establish VA as a leader and innovator


in health care redesign

VA proposes to identify core competencies and develop a high-performing network in


the future, which allows flexibility to determine excessive burden and account for clinical
conditions (Introduction: The Future of VA Health Care).
The development of a high-performing network for the New VCP will allow VA to
determine excessive burden for the ill and elderly and establish more sensitive standards
for geographic access to care while having confidence that those standards can be met
by the VA community network (Element 1: Single Program for non-Department Care
Delivery).
By establishing a single set of eligibility requirements, a high-performing network, and a
streamlined authorization process, the New VCP aims to improve Veterans access to
care (Element 6: Provider Eligibility and Element 8: Infrastructure).
The New VCP will consolidate existing purchased care mechanisms into a single
program and set of processes that will reduce confusion and improve access to care
(Element 1: Single Program for non-Department Care Delivery).
The New VCP will be designed using industry best practices and will evolve over time to
support access to high-quality care provided at VA or in the community (Element 1:
Single Program for non-Department Care Delivery).
A tiered network will be developed to better serve Veterans, support adequate coverage,
and provide access to high-quality care (Element 8: Plans to Use Current
Non-Department Provider Networks and Infrastructure).
The New VCP will be designed using leading practices from industry and will evolve to
incorporate innovative delivery and payment models (Chapter 1: Single Program for nonDepartment Care Delivery).
The New VCP will be implemented using a system of systems approach that considers
the interactive and interdependent nature of internal and external factors to optimize
outcomes and experience for Veterans (Element 1: Single Program for non-Department
Care Delivery).

Assessment C. Care Authorities


VA and Congress should articulate a
clear strategy governing the use of
purchased care.
VA should collect better data to
accurately estimate the demand for and
use of purchased care.

VA should develop a stronger program


management structure for purchased
care and allocate responsibility and
authority to the most appropriate levels.
VA should develop clear, consistent
guidance and training on its authority to
purchase care.

VA purchased care contracts should


include requirements for data sharing,
quality monitoring, and care
coordination.
VA and Congress should adopt a
consistent strategy for setting

This report provides Congress with VAs proposal for a clear strategy and direction for
community care, including required legislative authorities (Element 1: Single Program for
non-Department Care Delivery).
The New VCP proposes approaches for High-Performing Network Development,
including analytics, that are adaptable over time and can adjust to meet the needs of a
changing Veteran population, providing them with access to a tiered network (Element 8:
Plans to Use Current Non-Department Provider Networks and Infrastructure).
VA will designate a new DUSH to establish national management of and accountability
for community care and integration with VA provided care (Element 1: Single Program
for non-Department Care Delivery).
Similarly, at the local level, the New VCP will also standardize community care within
facilities to support consistent management (Element 1: Single Program for
non-Department Care Delivery).
This report includes a transition plan with change management and training necessary to
streamline existing programs and implement improved processes (Element 10:
Transition Plan).
By developing a High-Performance Network, VA plans to implement standards that
improve data sharing, monitoring, and care coordination (Chapter 6: Plan to Develop
Provider Eligibility Requirements and Element 9 Medical Records Management).
VA will identify top performers, measure provider productivity, and develop incentives
such as value-based payments (Element 6: Plan to Develop Provider Eligibility
Requirements and Element 9 Medical Records Management).
The New VCP proposes consistent reimbursement rates tied to regional Medicare.
Rates recommendations include exceptions for specific underserved geographic areas
(e.g., Alaska, Hawaii, Guam, Puerto Rico, American Samoa, and the Commonwealth of

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Plan to Consolidate Community Care Programs

Independent Assessment
Recommendation

Description of Alignment to New VCP

reimbursement rates across purchased


care initiatives.

VA should consider adopting


innovative, but tested, ways to
purchase care.
VA and Congress should eliminate
inconsistencies in current authorities
and provide VHA with more flexibility to
implement a purchased care strategy.

the Northern Marianna Islands); negotiated rates for services not covered by Medicare
rather than VA paying billed charges (Element 5: Provider Reimbursement Rates).
The New VCP will strengthen existing relationships with DoD, IHS, Tribal, and FQHC
partners (Element 5: Provider Reimbursement Rates).
Over time, the New VCP will evolve to include innovative practices from industry for
purchasing care, such as shifts to bundled or value-based payments (Element 1: Single
Program for non-Department Care Delivery).

The New VCP proposes to eliminate inconsistencies between various purchased care
mechanisms by establishment of a single program (Element 1: Single Program for
non-Department Care Delivery).

The New VCP will be flexible to provide access to care through a high-performing
network as demand changes (Element 8: Plans to Use Current Non-Department
Provider Networks and Infrastructure).
Services provided in the network will be complementary to internal VA health care
delivery (Element 8: Plans to Use Current Non-Department Provider Networks and
Infrastructure).

Assessment D. Access Standards


Care delivery sites should continuously
assess and adjust the match between
the demand for services and the
organizational tools, personnel, and
overall capacity available to meet the
demand, including the use of alternate
supply options, such as alternate
clinicians, telemedicine consults,
patient portals, and web-based
information services and protocols.

Assessment H. Health Information Technology


VA should explicitly identify mobile
applications as a strategic enabler to
increase Veteran access and
satisfaction and help VHA transition to
a data-driven health system.

Enhancing the mobile apps portfolio to support the future state continuum of care
coordination, including aspects of patient navigation, secure messaging and mobile Blue
Button (Introduction: Care Coordination).

VA will pursue a claims solution and simplified processes as it evolves to achieve parity
with best practices, working toward consistent, timely payment (Element 4: Billing and
Reimbursement).
The New VCP develops a single, streamlined billing and reimbursement process to
support the program (Chapter 1: Single Program for non-Department Care Delivery).

Assessment I. Business Processes


VHA: Develop a long-term
comprehensive plan for provision of
and payment for non-VA health care
services.
VHA: Standardize policies and
procedures for execution of non-VA
Care, particularly The Choice Act, and
communicate those policies and
procedures to Veterans, VHA staff,
VHA providers, and non-VA providers.
VHA: Employ industry standard
automated solutions to bill claims for
VHA medical care (revenue) and pay
claims for non-VA Care (payment) to
increase collections to improve
payment timeliness and accuracy.

VA will standardize business rules and processes under a uniform system (Element 10:
Transition Plan).
The transition plan lays out the key elements of the change management plan necessary
to communicate changes in community care programs and processes to all stakeholders
(Element 10: Transition Plan).
Under the New VCP, VA will pursue a claims system that employs best practices,
standardized business rules, and auto adjudication, that will help it ensure compliance
with the Prompt Payment Act (Element 4: Billing and Reimbursement and Chapter 7:
Prompt Pay Compliance).

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Plan to Consolidate Community Care Programs

Independent Assessment
Recommendation
VHA: Align performance measures to
those used by industry, giving VHA
leadership meaningful comparisons of
performance to the private sector.
VHA: Simplify the rules, policies, and
regulations governing revenue, non-VA
Care, eligibility, priority groups, and
service connections, educate all
stakeholders, and institute effective
change management.

Description of Alignment to New VCP

VA will adopt clinical and administrative best practices under the New VCP using data on
Veterans needs and the quality of providers that will allow for parity inside and outside
of VA (Element 1: Single Program for non-Department Care Delivery).

The New VCP defines a single set of eligibility requirements for the circumstances under
which Veterans may choose to receive health benefits from community providers,
enabling timely and convenient access to care in alignment with best practices (Element
2: Patient Eligibility Requirements).
The New VCP will also include plans to communicate these changes to stakeholders
(Element 2: Patient Eligibility Requirements).

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